Presentation on theme: "Early Intervention in Psychosis Alison Blair, Consultant Psychiatrist Janice Harper, Consultant Clinical Psychologist."— Presentation transcript:
Early Intervention in Psychosis Alison Blair, Consultant Psychiatrist Janice Harper, Consultant Clinical Psychologist
Esteem Glasgow Patient group yrs with first episode psychosis Assessment and treatment In- patient and out-patient care, crisis and assertive outreach Working with families Maximising recovery Minimising trauma
ESTEEM Clinical Model Home based care Formulation derived care plan Integrated Care Pathway Holistic approach Evidence based interventions with timely access to psychological therapies ( 70 % caseload referred to Clinical Psychology) Co morbidity ( 66% substance/alcohol abuse, 35% depression, 10% Autistic Spectrum Disorder)
Currently 3 teams across Greater Glasgow Clinical Co-ordinators Community Psychiatric Nurses Occupational therapists Support workers Consultant and other grades of Psychiatrist Consultant and other grades of Clinical Psychologist
DELIVERY TARGETS (from relevant ICP Condition-Specific Standards / ESTEEM Policies) Psychoeducational, psychological, psycho-social therapies delivered within 3 months of referral, with subsequent reviews of individual ’ s progress Evidence based medication algorithm is followed, including for medication resistant psychosis (e.g. SIGN; NICE guidelines) If patient disengages, continue to engage with family as required OR transfer of care between services / discharge to GP. If discharged < 2 years, log reason for discharge Correspondence updating GP at a minimum of every three months Suspected psychosis: Assessment within 5 days Allocate key-worker Assertive engagement Collateral history Assessment discussed with MDT MDT assessment if required Depression Screening (BDI-II) If discharge: Inform referrer of assessment outcome / advise re. re-referral if problems persist MDT Formulation within 12 weeks, inc. plan of interventions Review of 1 st care plan 3 months from formulation 1. Self Report Questionnaires (BDI-II, AUDIT, DAST, SAS) at 0-6 weeks and 12 weeks completed by service-user with staff member 2. Self Report Questionnaires at 6 months and 12 months completed by service user with Research Assistant unless agreed for staff member to administer. 3. PANSS IS COMPLETED BY PSYCHIATRIST (with negotiation this can be passed on to other PANSS trained staff) 4. Service Engagement Scale and AUS/DAS are completed by key- worker in collaboration with MDT (e.g. at formulation session) 5. ECGI is completed by ‘ carer / main social or practical support figure in client ’ s life ’ with RA or staff member OUTCOME MEASURES & FORMS Complete the following for all confirmed cases of First Episode Psychosis Client & Carer Consent Procedures Positive and Negative Syndrome Scale (PANSS) Beck Depression Inventory (BDI-II) Alcohol-Use Disorders Identification Test (AUDIT) Drug Abuse Screening Test (DAST) Alcohol & Drug Use Scales (AUS/DUS) ESTEEM Service Receipt Inventory (Entry Form – completed by 6 weeks) PANSS BDI-II AUDIT/DAST/AUS & DUS Service Engagement Scale (SES) & Service Attachment Scale (SAS) Experience of Care Giving Inventory (ECGI) ESTEEM Service Receipt Inventory (3 month) Consider if at risk of arrested recovery if SES score > 12 and prioritise formulation / re- formulation PANSS BDI-II SES SAS Process of Recovery Questionnaire (QPR) ESTEEM Service Receipt Inventory (6 month) Consider if at risk of arrested recovery if SES score > 12 and prioritise re-formulation PANSS BDI-II SES SAS AUDIT/DAST/AUS&DUS QPR ECGI ESTEEM Service Receipt Inventory (1 year) Consider if at risk of arrested recovery if SES score > 12 and prioritise re-formulation PANSS BDI-II SES SAS AUDIT/DAST/AUS&DUS QPR ECGI ESTEEM Service Receipt Inventory (2 year) Consent to long-term follow-up Exit Interview ICP REVIEWS: DOCUMENTS & ASSESSMENTS Risk assessment ADMIN: Personal Data Sheet Standard letter acknowledging referral sent to GP / referrer ICP diary initiated from date of acceptance onto ESTEEM caseload PSYCIS Physical Health Check GASS Initial assessment document to GP/referrer with outcome (acceptance/discharge) ICP Review Meeting ICP Indicator Forms (OT / Psychology) AVON HONOS GASS Glasgow Risk Scale Copy of ICP care plan to client/GP ICP Review Meeting Glasgow Risk Scale Copy of ICP care plan to client/GP Schedule annual MDT case discussion ICP Annual Review Glasgow Risk Scale GASS Physical Health Check Copy of ICP care plan to client/GP ICP Indicator Forms (OT/psychology) Predischarge ICP review AVON HONOS GASS Glasgow Risk Scale PSYCIS Physical Health Check Transfer of Care Document, inc. copy to GP REFERRAL0 - 6 WEEKS3 MONTHS6 MONTHS1 YEAR2 YEAR ESTEEM First Episode Psychosis Service NHS Greater Glasgow & Clyde
SIGN Recommendations There is consistent evidence that EI services have benefit for engagement rates, readmission rates, access to family interventions and other psychological interventions and rates of functional recovery in patients with first episode psychosis.
Cost Effectiveness of Early Intervention “Early Intervention costs more in the first year of care (compared to standard care) because of the higher rates of contacts with multi professionals, thereafter per patient EI costs considerably less than standard care, largely due to inpatient savings” ( Knapp et al., 2011) “ If EI services extended to cover the total population of England, estimated net savings to the NHS would amount to £290 million, increasing to £ 550 million if wider economic savings were taken into account” Department of Health
Glasgow Edinburgh First Episode Psychosis Study Three centres in Glasgow (ESTEEM), Edinburgh (EPSS and Adult CMHT services) Study aimed to characterise a sample of participants, investigate the role of attachment in the evolution of psychiatric symptomatology and service engagement
OUTCOMES DUP Edinburgh 23 weeks vs Glasgow 13 Days as in-patients Edinburgh 72 vs Glasgow 33 ( in first 12 months) Glasgow patients had less positive symptoms and lower scores on general psychopathology
Figure 2.4b: Five-fold variation in bed days for admissions with a primary diagnosis of psychosis for individuals aged years
EI in Psychosis Service Delivery
The Mental Health Policy Implementation Guide (DOH 2001) 14 to 35 year age entry criteria 14 to 35 year age entry criteria First three years of psychotic illness First three years of psychotic illness Aim to reduce the duration of untreated psychosis to less than 3 months Aim to reduce the duration of untreated psychosis to less than 3 months Maximum caseload ratio of 1 care coordinator to 10– 15 clients Maximum caseload ratio of 1 care coordinator to 10– 15 clients For every 250,000 (depending on population characteristics), one team For every 250,000 (depending on population characteristics), one team Total caseload 120 to 150Total caseload 120 to doctors per team1.5 doctors per team Other specialist staff to provide specific evidence based interventionsOther specialist staff to provide specific evidence based interventions
NEIP Core service features (2005) Stand-alone service model Dedicated consultant psychiatrist input Full age range (14^35 years) Care provided for up to 3 years Assertive community outreach work Extended opening hours Case-loads of 10^15 Adolescent provision Primary care referral Designated access to acute beds
Models of implementation in UK Specialist Team Model The service is provided through a stand-alone specialist team. All staff work predominantly for the team and have a shared task to provide EIP services. This is the model based on evidence from early EI and Assertive Outreach services.
Dispersed or CMHT Model The service is provided by staff (full or part-time) embedded within an existing service, usually a Community Mental Health Team (CMHT). Staff are expected to follow core principles of care, but often have limited contact with people in similar roles. Limited evidence (See Fowler et al. 2009)
Hub and Spoke Model This model is a cross between the above two models. The service is provided by staff who are be embedded in ‘spokes’, often CMHTs, and in the central ‘hub’. The hub usually provides access to leadership, specialist skills and support to the spoke workers. This model is often found in rural areas.
Benefits and deficits of EIP service models (Dodgson & McGowan, 2010) Specialist Dispersed H & S Specialist Dispersed H & S Evidence Base to support X X Promotes team approach X X Promotes clear EIP value base/philosophy X ? Consistency of practice X Consistency of practice X Promotes recruitment and retention ? ? Promotes development of specialist skills X ? Strong local presence X Strong local presence X Value for money ? ? May benefit other community teams ? community teams ? Easy to ring-fence EIP resource X ?
Outcomes from service models Fowler et al (2009) compared comprehensive EI service with CMHT service with specialist EI workers attached to CMHT: Generic CMHT, only 15% individuals made full or partial recovery at 2 years. Specialist EIP workers in collaboration with traditional CMHT care, 24% made a partial or full recovery. Comprehensive EI service, 52 % made full or partial recovery at 2 years and significant reductions in admissions was an added benefit.
Delivering EIP Each model has strengths and weaknesses Specialist team best outcomes Challenge is to establish the model that is most pertinent to the needs of the locality but also meets the core service features and clinical interventions that evidence shows are required for successful EI. EIP has to be value for money therefore promised outcomes must be achieved Risks in alternative service models are that outcomes are not achieved
A key challenge for us all is delivery of EIP, not just in urban inner city areas but also in rural settings
EIP Service Delivery Best practice principles Evidence base and Early Psychosis Declaration But Demography, geography, resources, financial pressures mean compromise. What principles of EI are non negotiable? Practical and effective
Minimum Fidelity Standards for New EIP Services (NIMHE 2005) Involvement of all stakeholders including CAMHS in service planning Optimally a discrete specialist team or hub & spoke that meets minimum standards for team definition A coherent group of specialist practitioners whose sole/main responsibility is EIP with common aims and objectives, philosophy of care and agreed care standards Explicit leadership that provides specialist supervision, work allocation,fidelity monitoring, service & staff development and performance management Assertive outreach to those who require it Clarified medical responsibility for patients Interventions: as per policy implementation guide Capacity: sufficient capacity to meet the actual level of local need Capacity to be based on care-coordinator caseloads of and an intention to see clients for 3 years Audit and Information: local information gathered to enable audit including evaluations of outcomes
Essential clinical components of EI Staff trained in EI approach and interventions ICP to guide and ensure fidelity True MDT work incorporating all disciplines including dedicated Consultant Psychiatrist and Psychologist Comprehensive MDT assessment Developmental history from family members Assessment of family functioning Formulation driven care plan Highlights potential barriers and risks and directs specific interventions Ongoing family work including formal therapy where indicated Intensive support and outreach to engage Crisis function
Discussion Delivering EI in Rural locations: which model? What is your expected caseload of 1 st Episode Psychosis? For every 250,000 (depending on population ( For every 250,000 (depending on population characteristics), one team ; Total caseload 120 to 150) characteristics), one team ; Total caseload 120 to 150) Is EI currently being delivered? What are the current resources? What skills training would be required?