Principles, Standards and Practice in Early Psychosis

1
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

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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.

3
Mental Health reformin Nova Scotia

• 2000Bland-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.

4
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.

5
Mental Health Standardsin Nova Scotia. February
2003

• Generic Service standards
• Accreditation
• Access
• Generic service delivery standards
• Planning, evaluation and monitoring
• Human resources
• Governance and funding

6
Mental Health Standardsin Nova Scotia February
2003.

• 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).

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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

8
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.

9
Early Psychosis background material

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

10
Early Course of Psychotic Disorders


Start Treatment
Onset Positive Sym

• illness
  duration
• 
  psychotic episode duration
• (Adapted from Larson 1996)

Functional decline
premorbid
at risk phase
psychosis
remission
first treatment
(prodrome)
DUP
Illness onset episode onset
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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.

12
History

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

13
Emergence of the field of Early Psychosis

• Late 1980s
• UK attempts at pre-psychotic intervention (Ian
  Falloon).

14
Early Course of Psychotic Disorders


Start Treatment
Onset Positive Sym

• illness
  duration
• 
  psychotic episode duration
• (Adapted from Larson 1996)

Functional decline
premorbid
at risk phase
psychosis
remission
first treatment
(prodrome)
DUP
Illness onset episode onset
15
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).

16
Time course of treatment response Lieberman et
al, 1993
17
Percentage of Patients Meeting Criteria for
Symptom Remission
18
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.

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Emergence of the field of Early Psychosis 3-

• Early 2000s
• 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.

20
Early Course of Psychotic Disorders


Start Treatment
Onset Positive Sym

• illness
  duration
• 
  psychotic episode duration
• (Adapted from Larson 1996)

Functional decline
premorbid
at risk phase
psychosis
remission
first treatment
(prodrome)
DUP
Illness onset episode onset
21
Existing standards and guidelines in Early
Psychosis

• Australian Clinical Guidelines for Early
  Psychosis, 1998.
• Clinical Guidelines and Service Frameworks
  Initiative to Reduce the Impact of Schizophrenia
  UK, 2001.
• Early Psychosis Care Guide, T. Ehman and L.
  Hansen, UBC, 2002.
• Consensus statement principles and practice in
  early psychosis International Early Psychosis
  Association, 2002.

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Consensus StatementInternational 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.

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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 its 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.

24
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.

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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.

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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.

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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 250-400 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.

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Early Psychosis Service Model Nova Scotia

• Three components
• Health Districts (nine) and the IWK.
• Community partners including primary care.
• Provincial Early Psychosis Program.

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Provincial Early Psychosis Services Model
Children, Youth and Adults
Provincial
District/Shared District/IWK
Local
Network

• 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.

• 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..

• 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.

7/26/2009 717 PM
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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.

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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.

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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.

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Provincial Early Psychosis Services Model
Children, Youth and Adults
Provincial
District/Shared District/IWK
Local
Network

• 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.

• 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..

• 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.

7/26/2009 717 PM
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Service standardsNova 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

36
Service standardsNova 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

37
Service standardsNova Scotia

• E4.3
• Prompt assessment. Suspected psychosis considered
  either an emergency (days).
• Evidence II
• I Research based evidence
• II Expert consensus
• III Expert opinion
• IV Opinion of stakeholders

38
Service standardsNova 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

39
Service standardsNova 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

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Service standardsNova 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

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Service standardsNova 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

42
Service standardsNova 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

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Service standardsNova 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

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Generic Service standardsNova 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/treatmentreceive
  continuing education/training required for their
  level of service provision.

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Web sites

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