1. Earlier intervention in psychosis - everybody’s business A primary care view Dr David Shiers Dr Jo Smith Joint leads NIMHE National EI Programme Haugesund. Workshop on primary care. Sept 2 nd 2008

2. Learning objectives  Explore the interface between psychiatry and primary care  Develop a marketing strategy to ‘sell’ early intervention to primary care colleagues

4. At any one time is responsible for: –10-20 registered on his/her list with psychosis –30-50% without any support from specialist care (Kendrick,2000) Average GP (list 1800) sees each yr: –250 new mental health cases –5 with severe mental health problems –1 with a first episode of psychosis

5. Continuity –Alertness to changes in behaviour and functioning which may precede first episode and relapse –Potential for better physical health care Care setting –More accessible and less stigmatising Context: –Knowledge of individual before onset of psychosis –Family practice

6. Some GP views: “I know that I cannot look after people with severe and enduring mental health problems. I do not have the skills or the knowledge. I couldn't do it well" “Sometimes they have to be standing on a bridge before we can get people help and we have to exaggerate symptoms to get the psychiatrist’s attention at an earlier stage” Helen Lester BMJ 2005

7. Contrasting with patients’ views typified by: "I mean, the GP has to have some understanding of mental health but I don't expect my GP to know all of the issues to do with my illness......I would though expect him or her to refer me to a specialist person. The important thing is that somebody is looking after you so it's not just you on your own.” Helen Lester BMJ 2005

9. Victoria (Aus) Burden of Disease Study: Incident Years Lived with Disability rates per 1000 population by mental disorder GPs see a FEP at an age when other serious mental disorders tend to develop

10. Pathways to Care Audit Data and GP Survey  North Staffs Pathways to Care prospective audit n = 45 (Macmillan, Ryles, Shiers & Lee 1998/9)  Sandwell GP interview n = 3 (Alderton 2000 )  Worcester Pathways to Care retrospective audit n = 30 and GP workshop n = 26 (Smith 2000)  Walsall Pathways to Care review from case notes n = 18 (Rayne 2002)  Gloucester GP Postal questionnaire n = 15 (Davis 2002)

11. Who are they?  50% < 24; youngest aged 13  Average age at onset = 21  75% live with parent(s) or spouse  41% are employed or in full- time education

12. Pathway players (n = 45)

13. Symptoms presented to GPs?  7% - clear evidence of psychosis  37% - physical / somatic symptoms  50% report emotional and psychological changes  25% report changes in work and social functioning

14. Nature of their help-seeking to GP?  Prodrome: typically 2 – 6 m  ~ 50% seek help <2 wks of psychotic symptoms  ~ 20% of individuals have courage to seek help themselves  ~75% relied on family members to seek help on their behalf  5 contacts on average to achieve pathway to care  GPs are first point of professional contact ~ 65%

15. DANGER AHEAD!!! DANGER AHEAD!!! Pressure wave- trapped  7-15m treatment delays  Families’ concerns ignored  Crisis response is the rule –73–80% hospitalised –36–59% Mental Health Act –45% police involved  Lifetime suicide risk 10% – 2 / 3 within first 5yrs –around the FEP  50% disengage: likely crisis reengagement

16. Some get marooned…  Stagnation in a ghetto of disability  Relapse and remission  Path to social exclusion and health inequality? “…can’t get a job, can’t get a girlfriend, can’t get a telly, can’t get nothing… it’s just everything falls down into a big pit and you can’t get out…” Hirschfeld, 2002 “…our overwhelming feeling was of an opportunity missed - to what degree she has been needlessly disabled by those first four years of care we’ll never know” Mother 2002

17. ... a path to inequality  Excluded  12% with a job  In previous 2 weeks (Nithsdale survey) o39% either had no friends or had met none o34% had not gone out socially o 50% no interest or hobby other than TV  one in four have serious rent arrears  3x divorce rate  Dis-ease  up to 25 years less life  33% suicide and injury  66% premature deaths from physical disorders Eg. Deaths due to coronary heart disease: kills more than two-thirds of people with schizophrenia, compared with about a half in the general population, Accounted for by excess smoking; obesity; hypertension; diabetes Antipsychotics – link with obesity, diabetes (up to 5x rate) Lifestyle issues – poverty, diet, exercise, smoking (2x rate) Poorer health care – poor access to physical health services; discrimination; diagnostic overshadowing

18. That’s the problem we are trying to solve

19. What do young people and families need? Optimism Confidence in a whole systems response to their help- seeking Earlier detection –of psychosis –of ‘at risk mental state’? Specialist services that –‘do psychosis’ as well as ‘do young people’ –pre-empt crisis; offer less traumatic ‘first engagements’ –offer age / phase specific care in ‘critical period’ of first 3-5 yrs –provide recovery oriented services from the start Support for families

20. What do specialist services need from primary care? GPs as key pathway players to: –Listen for and act on family concerns –Be aware of key indicators –Be flexible and accessible to promote help- seeking of these young people –Involve EIS at the earliest opportunity –Organise care to meet physical health need

21. What does primary care need from specialist services? Youth friendly approach – ban outpatient clinics! Low threshold of access to specialist advice –MH assessment of those with suspected FEP –Monitoring / review of those deemed at ‘high risk’ of FEP –Individual support for FEP Collaborative approach –Clear pathways (e.g. for those aged 14-18; for those with co-morbid drug misuse) –Relapse planning –Planned exit from EIS

22. Marketing EI to primary care?

23. Colin’s journey

24. Rapids Eddy Family PC Family crisis Drop out of Educ’n Isolated from friends Suicide attempt Offending behaviour Mental illness Homeless Drugs Rapids Rapids No money Distressed No job Youth worker

25. Using Nature – Eddies Early detection of danger ahead  Pull ashore, get out, take a look and regroup  Use understanding of the nature of the journey and knowledge to stop and even regain some ground

26. Safety raft White water Rapids Eddy Family Guides Lookout with life ring

27. Supporting GPs’ to do a difficult job better:

28. Acknowledgements to: Dr. Roy Morris Dunedin and Dr Maryanne Freer, Newcastle for contributing the white water rafting metaphor and to Guzer.com for the images Early intervention is everybody’s business  EI services insufficient by themselves  GPs offer continuity, context and family practice: –Key role in care pathway of those with emerging psychosis –Ability to listen and act on concerns of the family –In it for the long term –EI for bodies as well as minds Equipped for the life ahead both for the young person and their family

29. david.shiers@csip.org.uk joda@lineone.net www.earlydetection.csip.org.uk Thank you