1. Key Activities of an ARMS Service Dr Samantha Bowe Clinical Psychologist / Clinical Lead for EDIT Services BSTMH NHS Trust

2. Acknowledgements  Salford EDIT Team Dr Sophie ParkerMaria Kaltsi Clinical PsychologistAssistant Psychologist Rory ByrneSarah Ford Service User RepresentativeAssistant Psychologist Jane Foster PA/ Team Secretary  Dr Paul French / Prof Tony Morrison Associate Directors in Early Intervention

3. Identification Young People At-Risk of Psychosis  Training with potential referrers to help recognise ‘at-risk’ signs  Information: attenuated route / BLIPs / family route / service delivery / leaflets for client  Primary Care Checklist for guidance  Assessment using specific ‘at-risk’ measure e.g. CAARMS  Clear feedback to referrers of outcome

4. Primary Care Guidelines for Identification of Suspected or First Episode Psychosis 19.7.02 EDIT 0161 772 4350 EI team 0161 745 2254 CMHT Crisis Team If immediate risk Sub-threshold/uncertain diagnosis Clearly first episode psychosis

5. Referral Pathways Referral Source No. Referred Community Mental Heath Teams Youth Offending Team Primary Care Psychology Services General Practitioner (GP) Early Intervention Team Inpatient Unit Housing Agencies Connexions Crisis Team Drug Services Self Referral FamilyCAMHS Assertive Outreach 26191777765442221

6. Evidence Based Interventions  Preventative approach with developing evidence base  Important to draw on evidence base so far  Not automatically replicate existing models & treatments used in mental health (e.g. CMHT / EI)  Different client group – often younger, not yet made transition :- ethical issues

7. Evidence Based Interventions  Cognitive Therapy  Effective at preventing transition to psychosis  Transition rates (12 months post CT): cognitive therapy: 6% monitoring alone: 22% monitoring alone: 22% If no intervention at all: Yung et al. (1998) – 40%@ 6mths If no intervention at all: Yung et al. (1998) – 40%@ 6mths  Salford EDIT 2006-2007: 8% transition rate  Evidence base for psychosis, anxiety, depression etc. Helpful for false positive group.

8. Evidence Based Interventions  Collaborative, normalising, individual problem list & goals, formulation to inform intervention strategies.  Acceptable intervention for clients: low drop out rate in EDIE I

9. Drop Out Rates % of dropouts McGorry et al. 2002 [CBT plus risperidone] McGlashan et al. 2006 [Olanzapine] Morrison et al. 2004 [CT]

10. Case Management  Social difficulties increase risk of psychosis & other mental health problems  Case management located in EDIT  Promotes engagement  Assist & promote use of mainstream services (e.g. housing, benefit agencies, connexions). Balance help with promoting independence.

11. Anti-Psychotic Medication  Lack of evidence base so far  PRIME study: McGlashen et al. (2003) olanzapine 5-15mg a day for 1 year, 12 mth follow up olanzapine 5-15mg a day for 1 year, 12 mth follow up Transition rates: olanzapine = 16 % Transition rates: olanzapine = 16 % placebo = 37% placebo = 37%  Side effects / ethical issues  If not effective, less compliance if make transition?  Follow International Clinical Practice Guidelines for Early Psychosis (2005)

12. Anti-Psychotic Medication  Anti-psychotics not usually indicated unless person meets criteria for psychosis  Exceptions: severe suicidal risk, rapid deterioration, treatment of depression ineffective, aggression poses risk to others  Low dose for trial period  EDIT: if prescribed anti-psychotic contact referrer to discuss rationale / info. packs  Training slot: SPR’s in Trust: info. packs / International Clinical Practice Guidelines

13. Monitoring  Regularly repeat assessment measures to Ensure effectiveness of interventions & monitor mental state over time to Ensure effectiveness of interventions & monitor mental state over time  Monitoring offered up to 3 years even if not engaged with other aspects of service  Reduce DUP  If at-risk at monitoring appt. – booster sessions / or increase contact  Flexible: consent for face to face contact / phone or e-mail etc.

14. Duration Of Untreated Psychosis  Greater length of time between onset of psychosis & receiving treatment the worse the prognosis  Average DUP 1 year (Barnes et al. 2000)  ARMS service can reduce DUP  EDIT: 25% referred onto to EI with undetected first episode psychosis

15. Service User Involvement  Service user feedback  EDIT: Service User Representative – consultancy role on service development - interview panel for recruitment - interview panel for recruitment - service user forum / research - service user forum / research - someone clients to speak to when deciding whether or not to be seen for assessment or therapy - someone clients to speak to when deciding whether or not to be seen for assessment or therapy

16. Interface with Services  Ensure effective interface between services e.g. primary care, EI, CMHT’s, voluntary sector, A&E, CAMHS etc. e.g. primary care, EI, CMHT’s, voluntary sector, A&E, CAMHS etc.  Co-working: clear guidelines written into protocols (e.g. CAMHS, EI)  EDIT: primary care, link into established services when appropriate (e.g. A&E, CMHT’s, EI etc)  Responsive to risk

17. Family Involvement  Involvement of family / significant others for support & advice  With clients consent: regular feedback, psycho education, sharing of formulation, advice on how best to help, crisis plans / emergency no’s  Family intervention if appropriate

18. Awareness Raising  Awareness raising & education about psychosis in primary care, social care, voluntary sector, & education  Mental health promotional work in schools, colleges etc.  De-stigmatise psychosis: challenge misconceptions (increase likelihood of disclosure & positive response)  EDIT: currently providing staff training on range of mental health problems, not just on early signs of psychosis

19. Core Principles  Culture, age & gender sensitive - 66% clients in EDIT under 21 yrs - 66% clients in EDIT under 21 yrs  Service user & family focused - collaborative approach, individually tailored, based on clients’ ‘problem list’ & goals - collaborative approach, individually tailored, based on clients’ ‘problem list’ & goals - family involvement - family involvement  Meaningful engagement based on assertive outreach model - home visits, do not discharge due to non attendance, open door policy, flexible approach: e-mail, text etc. - home visits, do not discharge due to non attendance, open door policy, flexible approach: e-mail, text etc.

20. Core Principles  Low use of stigmatising settings (youth friendly, age appropriate, primary care settings, home visits) (youth friendly, age appropriate, primary care settings, home visits) - Fear of going mad common – important to keep in primary care (if see within a MDT setting: can be frightening, increase distress, effect engagement) - Fear of going mad common – important to keep in primary care (if see within a MDT setting: can be frightening, increase distress, effect engagement) - Service delivery in primary care setting (EDIT & GP) unless significant risk issues which require co-working with other services - Service delivery in primary care setting (EDIT & GP) unless significant risk issues which require co-working with other services  Recovery based principles: - meaningful activities - meaningful activities - valid social roles (college, work, relationships) - valid social roles (college, work, relationships)

21. Summary: Core Features ARMS Service Prevent Transition to Psychosis Reduce DUP Raise Awareness / Education Stigma

22. Summary: Core Features ARMS client Specialist Assessment Evidence Based Interventions Monitoring Up to 3 years Case Management Family Involvement

23. Summary: Core Features ARMS Service Recovery Focused PIG Compliant Good Interface with Other Services Primary Care Setting

24. Service User Quotes  “Like this psychology session, I mean if I had to go out and come to see everybody, the psychologist and things like that, I wouldn’t go out of the house and that’s why I never got no where for years, but when the counsellor did get me in touch with the psychologist, I knew I’d stick with them because they’d do home visits, because I don’t go out and I need help, but I need someone to come to me because I can’t do it”.

25. Service User Quotes  ‘like a dark cloud over your head, you can’t even sleep at night, just there thinking someone is going to come, I thought I was in a movie, I’m dreaming, but it’s not a dream’  ‘well, before I started to cut meself I’d think, “god, they’re just doing it for attention” but until you are actually in that situation you don’t understand what they are going through …you understand more then. You look at it in a different way’

26. Service User Quotes  ‘if you have someone like that to talk to it’s a lot more helpful than if you don’t because if you don’t you’re just thinking you’re going really mad’  ‘basically you’re just going over the same thought, you’re going “am I crazy?” and then you’re going “well, I’m not” and it’s just a big circle and then you’re conflicting with yourself but if you have someone there they can explain, like you say it to them, they come back with a different answer, they don’t come back with the same one that you think all the time and it changes the circle, it changes the pattern’

27. Service User Quotes  ‘yeah, I was like bubbly and confident and not shy and stuff like that. Because when I started to first cut meself I was losing all me confidence when I was depressed and I didn’t want to go out, I didn’t want to do me hair, I just wanted to stay in bed all day and that was when I kept on cutting meself and then like I’d been on anti depressants for a bit, (therapist) came here a few times, spoke to her, it was just all coming back, all me confidence coming back, just getting back to normal, how I used to be like before, y’know before it all started,’  ‘I’m proud of myself, I’m very proud of myself, oh my God, I’ve done good, it’s not easy, you know that’

28. References  Parker, S., French, P., Kilcommons, A., & Shiers, D. (2007). Report on Early Detection and Intervention for Young People at Risk of Psychosis.  Parker, S. & French, P. (2007). Implementation Guide.  Hardy, K. & Morrison, A. P. 2007. The journey into and through EDIT - a qualitative exploration of the experiences of our clients. Unpublished Doctorate Thesis. University of Liverpool.

29. Contact Details samantha.bowe@bstmht.nhs.uk Dr Samantha Bowe Clinical Psychologist / Clinical Lead for EDIT Services 0161 772 4350