City-Wide Audit: Incidence of First Episode Psychosis, Duration of Untreated Psychosis and Demographics

1. City-Wide Audit:Incidence of First Episode Psychosis, Duration of Untreated Psychosis and Demographics Principal Authors: Rob McFarland (Research Assistant), Dr Jo Nicholson (Clinical Psychologist - Research Lead), Rachel Simmonds (Assistant Psychologist) and Steve Day (Practice Development Lead, Early Intervention) Contributing Authors: Dr Mary Hamilton (Consultant Psychiatrist - Early Intervention), Guy Hollingsworth (Service Director) and Eileen MacDonald (West PCT)

2. Context 1- Rationale for Early Intervention • Delay between onset of psychotic symptoms and first treatment is usually between one to two years. • The longer the individual remains untreated, the greater the opportunity for serious physical, social or legal harm • The period of untreated psychosis has been shown to involve distress for individuals and their relatives including ineffective and demoralising attempts to get help. • Where disabilities develop, in either social or personal function, they usually do so in the first three years – ‘the critical period’ • Unemployment, impoverished social networks, loss of self-esteem will all develop most aggressively during the critical period • Long duration of psychosis prior to treatment has consistently been shown to be related to poor outcome • Giving neuroleptic treatment early improves outcome • Providing treatment early on improves the long-term course of psychosis and reduces the longer-term health care costs • Early treatment reduces the development of longer term ‘treatment resistant’ symptoms and the ‘revolving door’ syndrome of marked repeated relapse • 10% of all disabled people = psychosis • 45% total NHS direct care budget

3. Context 2 – Service Development • North PCT - (slim) pilot EIS since 2001 • South West PCT – EIS from January 2005 • West PCT – EIS from January 2005 • South East PCT - EIS from May 2005 • TARGETS • Service Caseload • Reduce Duration of Untreated Psychosis (DUP) • EI in psychosis is ….

4. Audit Method - 1 • Audit covers 1 year period - June 2004 to May 2005 Inclusion Criteria: • Young people (age 16-35) referred to Secondary Mental Health Services with either diagnosis of psychosis or strong suspicion of psychosis • Primary diagnosis of mood disorder or learning disability excluded • Co-morbidity of substance misuse included • Referred within last 2 months

5. Audit Method -2 • Audit covers 1 year period - June 2004 to May 2005 • Seeking all clients referred to secondary MH services • Existing psychiatric notes were interrogated for all patients meeting inclusion criteria • Duration of untreated psychosis (DUP) calculated as: Length of time from onset of psychosis to onset of treatment

6. Incidence • StHA estimate - 75 new cases per year • Birmingham estimate - 214 new cases per year • Sheffield City Wide Audit - observed rate in 1 year period 105 cases

7. Basic Demographics

8. Ethnicity – 38% BEM It should also be noted that the data obtained from local NHS databases may not be completely accurate. It appeared that although the majority of white client’s ethnicity had been inputted into the system, the ethnicity of non-white clients were missing in a number of cases. This may have resulted in an under representation of ethnic and black minorities recorded in the audit.

9. What happened between onset & baseline? • Changed accommodation – 38% • 28% moved in with relatives • 11% moved out from relatives to live alone • 50% of workers became unemployed • 13% of students became unemployed

10. Clinical Demographics - 1 • Diagnosis was not clearly recorded in the majority of cases • Hospitalised – 37% of which: • Use of MHA during first admission – 60% • Use of MHA at any point in admission - 76% • Mean age at first admission– 23 (16-35) • Mean admission length – 42 days (1-229) • Police involved in first admission – 26%

11. Clinical Demographics - 2 • Forensic Hx Ever – 39% Of which nearly ½ identified as related to their MH • Self Harm Ever – 44% Of which 35% multiple methods 63% within past 6 months • Alcohol use in past month – 72% • Drug use Ever - 81% Of which 55% polyuse Most commonly used drugs - 82% cannabis, 37% ecstasy, 31% amphetamines, 22% cocaine • Drug use in past month – 31%

12. Medication at Baseline • Antipsychotic – 72% • Antidepressant -37% • Benzodiazepine – 32% • Mood stabilizer – 2% • More than one of these – 27% • No medication – 20%

13. Duration of Untreated Psychosis Able to calculate DUP in 65% of cases: • Mean DUP – 7½ months • DUP range – 0 days - 7 years • Statistically significant difference between men (x= 8½ months) and women (x=5½ months) • No statistically significant difference for ethnicity, hospitalisation, illicit drug use, marital status, education • However, clinical points of interest - Longer DUP observed if: living with non-relatives or alone, unemployed, never used drugs, married • Complex interplay between living circumstances and employment status

14. Age at onset of psychosis

15. Home address at onset on deprivation map: (+ 8 outside Sheffield)

16. Conclusions • Clinical governance issues addressed re: case note quality • Observed incidence of 105 cases in 1 year period - less than the estimate funding is based upon, need continued monitoring over ‘reasonable’ time scale • Basic Demographics - Male, BME, student, unemployed, LD • Clinical Demographics - Self harm, forensic Hx, hospital, MHA • People move accommodation and lose jobs in DUP period • DUP & hospitalisation better than national average – but not very good • Broad similarity with comparison sample • FERN – is EIS working? • Research project provides more robust information as presented within this data set ++ includes additional information relating to pathways to care, detailed cased vignettes

17. Sheffield Early Intervention Service Netherthorpe House 101 Netherthorpe rd Sheffield S3 7EZ stephen.day@sct.nhs.uk 0114 226 4851 www.strangedays.org.uk