1. REDIRECT- Evaluating the Effectiveness of an Educational Intervention about FEP in Primary Care Helen Lester November 1 st 2007

2. Study team Max Birchwood Maria Michael Lynda Tait Nick Freemantle Amrit Khera Kate Harris Christopher John

3. Primary Care Policy Context  Primary care is viewed as increasingly important in mental health policy terms  Links between primary care and EI/FEP are still tenuous  Limited by incidence, knowledge and attitudes

4. Incidence of FEP  Most GPs will see one new person with FEP each year, and will have approximately 12 patients on their list with a diagnosis of psychosis  Similar incidence to meningococcal meningitis  Negative stereotypes still exist among GPs

5. GP Attitudes “When I approached my GP, he never gave me any hope that things could change. I remember being told that I’d never be able to work again, I’d never have an education, never have relationships, never have anything in my life.” P9, M, Cannock “Write him off!” P10, F, Cannock “That’s what they done. They never told me there are people who do recover, so it’s not a life sentence.” P9, M, Cannock

6. GP Attitudes “Well, some people don’t come when they’re well and some don’t come when they’re sick and to be honest it’s a bit of a relief because I can catch up on being late.” GP4, F, Worcester “They are notoriously bad at keeping appointments.” GP8, F, Birmingham Lester HE, Tritter JQ, Sorohan H. Providing primary care for people with serious mental illness: a focus group study. British Medical Journal 2005;330:1122-1128.

7. The Role of Primary Care in FEP  Primary care is potentially crucial in the detection and referral pathway (Skeate et al, 2002; Burnett et al, 1999)  May lead to a reduction in DUP?  Important in terms of ongoing family support

8. GPs and Referral Pathways (at some point) McGovern (1991) 62% n=62 Birmingham Cole (1995) 71% n=93 London Lincoln (1998)50% n=62 Melbourne Burnett (1999)46%n=100 London Skeate (2002)79%n=93 Birmingham

9. Working Practices in Primary Care  Random presentation of patients  10 minute time frame for assessment  269 million consultations each year, equivalent to 740,000 people (1.3% of the population) each day  Multiple drivers and “must do’s’”

10. Methods Fit the Culture of Primary Care Lack of research culture Competing priorities Question has to make sense to primary care Time/financial costs need to be minimal Minimal disruption to practice routine “Buy in” from PCTs

11. REDIRECT Methodology Cluster randomised controlled trial Not previously attempted in terms of FEP… Educational intervention of early detection training Primary outcome is number of referrals to EIS 160 patients (80 in each arm) Secondary outcomes of DUP, use of the MHA, time to recovery Recruitment from 5/4/04-7/2/07 All practices have equal access to EI teams Sampling frame of 300,000 patients across 2 PCTs in inner city Birmingham

12. Tailoring the Trial All data is collected in secondary care Training (intervention) is supported by the PCT Locum payments are made where additional training is required Training emphasises the key role that primary care can play Training imparts skills and knowledge i.e. has a CPD value as well Regular but unobtrusive contact Lester HE, Birchwood M, Tait L, Wilson S, Freemantle N. Design of the BiRmingham Early Detection In untREated psyChosis Trial:BMC Health services research 2005;5:19.

14. Developing the Educational Intervention Theoretical phase: literature review and exploration of attitude and behaviour literature (e.g. contact hypothesis) Modelling phase: focus groups and training needs analysis to explore what GPs wanted and needed to know and how the education should be structured and delivered

15. Content of the Educational Intervention Video illustrating consultations in primary care facilitated by a GP Written information e.g. challenging questions Year 2 and 3 follow up video training facilitated by service users and carers using the contact hypothesis

16. Expected Changes Knowledge: increased awareness of symptoms Skills: use of specific questions to elicit symptoms Attitudes: more positive attitudes towards young people with psychosis and their families

17. Consultation changes? Withdrawal from family and friends Loss of concentration Depression/anxiety Loss of trust Self neglect Hallucinations and delusions Thought disorder +Family history Drug misuse

18. Practice Recruitment and Training 148 practices approached in two waves of recruitment and 110 recruited (74.3%) 100% of practices had year 1 training, 69% year 2 and 50% year 3 65% of practices have had at least 2 training sessions Training well received Lester HE, Tait L, Khera A, Birchwood M. The development and evaluation of an educational intervention on first episode psychosis for primary care. Medical Education 2005;39:1006-14.

19. Results: Attendance and Feedback

20. Patient Recruitment Primary outcome (referred for possible psychosis, diagnosed as psychotic and then referred to EIS): 125 Those referred for possible psychosis, diagnosed as psychotic but NOT referred to EIS = 57 Total primary outcome of 182 Secondary outcomes: 83 with 6m follow up of 68

21. Results Neutral trial 9% increase in referrals from Intervention practices No change in any secondary outcomes except for delay in reaching EIS (p 0.002)

22. Comparison Difference Lower CI Upper CI P value Delay_in_help_seeking-105.97-267.4955.55840.1949 Delay_in_help_seeking_pathway4.0713-51.508659.65130.8842 Delay_in_reaching_EIS*222.0383.5375360.520.0021 Delay_within_MH_services87.3422-22.4520197.140.1170 Duration_of_prodromal_period59.3417-290.21408.890.7358 Duration_of_untreated_illness187.23-106.26480.730.2072 Duration_of_untreated_psychosis-13.7760-199.12171.570.8825 * time from first decision to seek care to referral to EIS

23. "Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things — to help, or at least to do no harm." Hippocrates: Epidemics, Bk. I, Sect. XI.

24. Did we do harm? False positive rate across the other mental health services in the 6m pre trial was 9/67 = 13.4% False positive rate in the subsequent 18 months was stable at 20/157= 12.7%

25. Who got stuck in services? 57 people in each of the 14 local MHTs Demographics were no different to the other EI group 52/57 included a clear reference to psychosis in the referral letter All were later confirmed as having a psychosis May have been a consequence of the waiting list in the EIS in 2004

26. Implications GP education does no harm GP education may simply do exactly what it says on the tin - enable GPs to diagnose young people more quickly and refer them to EIS GP education alone is not sufficient to increase referrals to EIS and decrease DUP  Primary care is just part of the jigsaw and interventions will need to be multifaceted

27. Thanks for listening