Principles, Standards and Practice in Early Psychosis David Whitehorn, PhD, RN, MScN Clinical Nurse Specialist and Coordinator Nova Scotia Early Psychosis Program Dalhousie University and Capital Health Halifax, Nova Scotia, Canada Early Psychosis Provincial Network and Standards Working Group 8 October 2004

Objectives Orientation to: –Nova Scotia mental health standards, specifically the early psychosis standards –The field of early psychosis Planning for: –The Nova Scotia Early Psychosis Network –Further development of the early psychosis standards Indicators Clinical guidelines and care maps.

Mental Health reform in Nova Scotia 2000:Bland-Dufton report. –Mental Health: A Time for Action. A consolidation of all previous reports as well as broad stakeholder input. Mental Health Steering Committee. Four major strategic directions.

Four strategic directions Enhancing public awareness and education to reduce the stigma associated with mental health issues. Facilitating meaningful ways for consumers, families and communities to influence mental health policy and services. Monitoring the mental health status of the population and health system performance relative to mental health outcomes. –HoNOS Developing Standards for consistent service delivery across the province and across all age groups.

Mental Health Standards in Nova Scotia. February 2003 Generic Service standards –Accreditation –Access –Generic service delivery standards –Planning, evaluation and monitoring –Human resources –Governance and funding

Mental Health Standards in Nova Scotia February Core mental health program standards. –Promotion, prevention and advocacy. –Outpatient and outreach services. –Community mental health supports. –Inpatient services. –Speciality services. Eating disorders Sex Offender treatment (children and youth).

Developing Early Psychosis service standards Provincial mental health steering committee. Provincial mental health standards committee (Linda Corey and Linda Smith). Early Psychosis standards working group. –Multidisciplinary, province wide representation, including IWK. –Mental health professionals –Consumer and family member –Schizophrenia Society

Nova Scotia service standards for Early Psychosis Deliverables: –A context and issues statement. –A service delivery model. –A set of standards related to the organization and operation of the delivery system.

Early Psychosis: background material Recent history of the field of Early Psychosis. Conceptual framework of clinical care. Existing standards and guidelines.

Early Course of Psychotic Disorders illness duration psychotic episode duration (Adapted from Larson 1996) premorbidat risk phasepsychosisremission DUP Start Treatment Onset Positive Sym Functional decline first treatment Illness onset episode onset (prodrome)

Fundamental issues and questions Psychotic disorders are severe and create enormous disability and suffering. Initial treatment is often delayed and fragmented. Timely and optimal (phase specific) treatment at the time the disorders first appear can limit suffering and may improve outcomes.

History We see too much of end stage schizophrenia and not enough of the first episode. –Harry Stack Sullivan, circa 1927 (paraphrased)

Emergence of the field of Early Psychosis Late 1980s –UK attempts at “pre-psychotic” intervention (Ian Falloon).

Early Course of Psychotic Disorders illness duration psychotic episode duration (Adapted from Larson 1996) premorbidat risk phasepsychosisremission DUP Start Treatment Onset Positive Sym Functional decline first treatment Illness onset episode onset (prodrome)

Emergence of the field of Early Psychosis Late 1980s –UK attempts at “pre-psychotic” intervention (Ian Falloon). –EPPIC development in Melbourne (Patrick McGorry). Mid 1990s –Australia develops national strategy. –EP programs appear in Australia, New Zealand, Europe, Scandinavia and the UK. –First Early Psychosis Programs appear in Canada (Halifax, London, Toronto, Calgary, Victoria).

Time course of treatment response; Lieberman et al, 1993

Percentage of Patients Meeting Criteria for Symptom Remission

Emergence of the field of Early Psychosis –2- Mid-Late 1990s –UK initiative (IRIS). Max Birchwood. –TIPS project in Stavanger, Norway. TK Larsen, Tom McGlashan –First randomized clinical trials for early psychosis patients (RIS-INT-35; 1996-). –Formation of the International Early Psychosis Association. First meeting in Hobart, 1998.

Emergence of the field of Early Psychosis –3- Early 2000’s: –Randomized clinical trials of ‘at risk phase’ interventions. –UK adopts Early Psychosis service to be available throughout the country 50 programs being developed –Publication of guidelines for service and practice by the IEPA.

Early Course of Psychotic Disorders illness duration psychotic episode duration (Adapted from Larson 1996) premorbidat risk phasepsychosisremission DUP Start Treatment Onset Positive Sym Functional decline first treatment Illness onset episode onset (prodrome)

Existing standards and guidelines in Early Psychosis Australian Clinical Guidelines for Early Psychosis, Clinical Guidelines and Service Frameworks; Initiative to Reduce the Impact of Schizophrenia; UK, Early Psychosis Care Guide, T. Ehman and L. Hansen, UBC, Consensus statement – principles and practice in early psychosis; International Early Psychosis Association, 2002.

Consensus Statement International Early Psychosis Association Clinical care is often delayed or inadequate. There are major opportunities for effective secondary prevention. –The pre-psychotic phase is prolonged with confusing symptoms and much of the disability is established during this phase. –The period of untreated psychosis is a risk factor for poor outcome. –The first psychotic episode and the early years of treatment deserve optimal, comprehensive, phase specific treatment with continuity.

IEPA Consensus: –2- Early identification combined with optimal treatment is likely to reduce the burden of disease. Early treatment of active psychosis is beneficial in it’s own right, but may also improve long-term outcomes. Community-wide education should be encouraged to help the public obtain effective advice, treatment and support.

IEPA consensus: –3- Low dose atypical antipsychotic medication strategies are preferred. Psychosocial interventions have a fundamental place in early treatment. Consumers and families need to be engaged as partners in developing better treatments and with the aim of validating their experiences of early psychosis.

Consensus Statement –4- Primary health care professionals should be competent to elicit and recognize early clinical features of psychotic disorders, as with other potentially serious and life-threatening illness. User-friendly access to assessment and treatment. Ideally, begin treatment before a crisis. Early intervention can allow engagement outside these emotionally charge situations, providing a safer and more positive start to treatment. Involve families in assessment and treatment plan.

Nova Scotia service standards for Early Psychosis A context and issues statement. A service delivery model. –Define three major components of a provincial service delivery system. –District, local, provincial components. Standards related to the organization and operation of the delivery system –A set of 10 standards. –Additional linkages to generic mental health standards.

Context and Issues in Early Psychosis DSM-IV disorders: –Schizophreniform, schizoaffective, schizophrenia, bipolar (with psychosis), psychosis NOS. Involves prodrome/at risk phase through first 2-5 years of treatment. Primarily involves youth. Estimated new cases/year in NS. Research demonstrates that Early Psychosis services can: –Reduce delay between symptom onset and treatment. –Improve adherence and engagement once treatment has started.

Early Psychosis Service Model Nova Scotia Three components: –Health Districts (nine) and the IWK. –Community partners including primary care. –Provincial Early Psychosis Program.

ProvincialDistrict/Shared District/IWKLocal Provincial Early Psychosis Services Model Children, Youth and Adults Provide clinical consultation. Develop & provide professional education / training. Develop & support psycho-education resources for individuals / families. Collaborate in development and implementation of prevention and public education initiatives. Promote & carry out research. Collaborate with DHAs/IWK to develop and carry out program evaluation. Coordinate and facilitate communication within a formal Early Psychosis network of designated staff from the DHAs and IWK.. Designate one or more mental health staff as liaison with the provincial Early Psychosis program and network. Participate in professional education/training. Provide intake, assessment and treatment. Provide individual / family education with support of resources developed by the provincial program. Identify and promote development of, and access to, local resources to support individuals and families. Collaborate in program evaluation activities. Facilitate referrals for participation in research. Collaborate in development & implementation of prevention and public education initiatives. Develop appropriate partnerships with local resources. 4/18/2015 2:27 AM Participate in education / training as appropriate. Collaborate in development & implementation of prevention and public education initiatives. Collaborate with DHAs / IWK to identify and promote development of local resources to support individuals & families. Collaborate in program evaluation. Network

Early Psychosis Service Model Nova Scotia Health Districts: –Provide clinical care, including patient and family education. –Designate an early psychosis coordinator(s) who participates in a provincial network. –Have staff participate in early psychosis education and training. –Partner to develop community supports. –Collaborate in public education initiatives. –Collaborate in program evaluation. –Support research.

Early Psychosis Service Model Nova Scotia Community partners: –Collaborate in development and operation of community supports. –Collaborate in public education initiatives. –Collaborate in program evaluation. –Participate in education and training as appropriate.

Early Psychosis Service Model Nova Scotia Provincial early psychosis program: –Facilitate the provincial early psychosis network. –Provide clinical consultation –Develop and support educational materials for professionals, patients, family and the public. –Collaborate in public education initiatives. –Collaborate in program evaluation. –Conduct and support research.

ProvincialDistrict/Shared District/IWKLocal Provincial Early Psychosis Services Model Children, Youth and Adults Provide clinical consultation. Develop & provide professional education / training. Develop & support psycho-education resources for individuals / families. Collaborate in development and implementation of prevention and public education initiatives. Promote & carry out research. Collaborate with DHAs/IWK to develop and carry out program evaluation. Coordinate and facilitate communication within a formal Early Psychosis network of designated staff from the DHAs and IWK.. Designate one or more mental health staff as liaison with the provincial Early Psychosis program and network. Participate in professional education/training. Provide intake, assessment and treatment. Provide individual / family education with support of resources developed by the provincial program. Identify and promote development of, and access to, local resources to support individuals and families. Collaborate in program evaluation activities. Facilitate referrals for participation in research. Collaborate in development & implementation of prevention and public education initiatives. Develop appropriate partnerships with local resources. 4/18/2015 2:27 AM Participate in education / training as appropriate. Collaborate in development & implementation of prevention and public education initiatives. Collaborate with DHAs / IWK to identify and promote development of local resources to support individuals & families. Collaborate in program evaluation. Network

Service standards Nova Scotia E4.1 Each district will have designated staff who participate in a provincial early psychosis network and liaise with the provincial program. Evidence: III –I Research based evidence –II Expert consensus –III Expert opinion –IV Opinion of stakeholders

Service standards Nova Scotia E4.2 Proactive outreach/referral finding (B2) is recognized as important. Multiple referral sources are accepted to maximize early detection. Evidence: II –I Research based evidence –II Expert consensus –III Expert opinion –IV Opinion of stakeholders

Service standards Nova Scotia E4.3 Prompt assessment. Suspected psychosis considered either an emergency (<24 hours) or urgent (<5 days). Evidence: II –I Research based evidence –II Expert consensus –III Expert opinion –IV Opinion of stakeholders

Service standards Nova Scotia E4.4 Assessment and treatment is provided by a multidisciplinary team, including primary care, who provide continuity and active engagement during the critical first 2-5 years of treatment. Evidence: II –I Research based evidence –II Expert consensus –III Expert opinion –IV Opinion of stakeholders

Service standards Nova Scotia E4.5 Consultation and supervision available at district and provincial level. Evidence: II –I Research based evidence –II Expert consensus –III Expert opinion –IV Opinion of stakeholders

Service standards Nova Scotia E4.6 Families are actively involved in assessment, engagement, treatment and recovery process with consent of individual and consistent with optimal care. Evidence: II –I Research based evidence –II Expert consensus –III Expert opinion –IV Opinion of stakeholders

Service standards Nova Scotia E4.7 Individuals and families are provided with comprehensive, current information related to psychosis, treatment, recovery and associated resources. Evidence: I –I Research based evidence –II Expert consensus –III Expert opinion –IV Opinion of stakeholders

Service standards Nova Scotia E4.8 Collaborative partnerships are developed to facilitate a comprehensive range of local resources to support individual and families. Evidence: II –I Research based evidence –II Expert consensus –III Expert opinion –IV Opinion of stakeholders

Service standards Nova Scotia E4.9 Public and professional education initiatives are undertaken to enhance prevention, early detection and early effective treatment in coordination with the DHAs/IWK and provincial planning initiatives, consistent with Standards Document Section A. Evidence: II –I Research based evidence –II Expert consensus –III Expert opinion –IV Opinion of stakeholders

Generic Service standards Nova Scotia Integrated mental health and specialty services for co-morbid disorders. Standardized initial assessment in all outpatient services. Standardized demographic, assessment and outcome data for program evaluation. Staff identified as part of a provincial specialty network and who provide specialized mental health assessment/treatment…receive continuing education/training required for their level of service provision.

Web sites iris-initiative.org.uk eppic.org.au cmha.ca/english/intrvent/ psychosissucks.ca