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Early Intervention in Psychosis Dr Charles Montgomery Consultant Psychiatrist Specialist Team for Early Psychosis

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Early Intervention in Psychosis Dr Charles Montgomery ... EI Cost Economic Data (McCrone, Dhanasari, Knapp 2007) EI Self Assessment Report 2007/08 Red ... – PowerPoint PPT presentation

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Title: Early Intervention in Psychosis Dr Charles Montgomery Consultant Psychiatrist Specialist Team for Early Psychosis


1
Early Intervention in Psychosis Dr Charles
Montgomery Consultant Psychiatrist Specialist
Team for Early Psychosis
Devon Partnership
NHS Trust
2
  • I have seen how much progress early intervention
    teams have made, how innovative they have been,
    and the impact they are having.   I now
    believe that early intervention will be the most
    important and far reaching reform of the NSF era.
      Crisis resolution has had the most
    immediate effect but I think early intervention
    will have the greatest effect on peoples lives.
  • Professor Louis Appleby,  National Director for
    Mental Health Oct 10th 2008  
  • Policies and Practice for Europe (DH  / WHO
    Europe conference attended by 35 European
    Countries)

3
Early Intervention in Psychosis
  • Early intervention in Psychosis is a
    paradigm of care for young people with a first
    episode psychosis and their families based on
    research and comprises three concepts
  • Early detection of psychosis
  • Reduce the long duration of untreated psychosis
  • Importance of the first 3-5 years following onset
    (critical period) for later biological,
    psychological and social outcomes

4
FEP typically commences in young people as do
many of the more serious mental disorders
Victoria (Aus) Burden of Disease Study Incident
Years Lived with Disability rates per 1000
population by mental disorder
5
Youth Health Services weakest when they need to
be strongest
  • The issue
  • CAMHS / adult interface and transition issues
    service centred rather than person centred
  • We need
  • Partnerships with youth agencies to develop
    comprehensive youth focussed services
  • Young peoples inpatient care and crisis
    provision
  • Youth sensitive service provision
  • Extend the EI Paradigm to other mental health
    disorders that have their onset in youth

6
RAISE COMMUNITY AWARENESS
IMPROVE ACCESS ENGAGEMENT
EARLY PSYCHOSIS DECLARATION
INTEGRATED HEALTHCARE
PROMOTE RECOVERY AND ORDINARY LIVES
ENGAGE AND SUPPORT FAMILIES
7
Duration of Untreated Psychosis is less than 3
months on average
90 of affected individuals report satisfaction
with their employment, educational and social
attainments
The use of involuntary treatment should be less
than 25
TRANSFORMATIONAL OUTCOMES
Suicide rates in the first two years after
diagnosis are less than 1
All 15 year olds are educated to understand and
deal with psychosis.
90 of families feel respected and valued as
partners in care
All generalist and specialist health and social
care practitioners know how to deal effectively
with early psychosis
8
Early Intervention Services Nationally
  • NHS Plan 2000. MH-PIG 2001. NICE 2002.
  • NHS Operating Framework 2009
  • 50 discrete and specialist UK services 120 UK
    teams
  • Young people 14-35 with 1st presentation and for
    3 years
  • Reduce risk of developing psychosis
  • Improve detection
  • Reduce delays in accessing treatment/reduce
    stigma.
  • Maximise recovery
  • Prevent relapse after first episode
  • Plan for continuing needs onwards care pathway

9
Early Intervention Provision (15,750 cases at
end of March 08)
2 teams 24 teams 41teams 109
teams 127 teams 160 teams 145services
10
What we do.
  • 5 self referral
  • 55 from Primary care
  • 15 other agencies F.E.P.
  • 25 wards Age 14-35
  • Contact within 48 hrs
  • Assessment within 7 days
  • 3- 6 month assessment
  • assertive engagement
  • Support for 3 years (low case loads)

11
Earlier AND better
  • Creative engagement process with assertive follow
    up
  • Low dose atypicals early
  • Family involvement from the start
  • Psycho-education
  • CBT
  • Practical help accessing training courses/work
    placements
  • Financial planning/support
  • Relapse prevention
  • Ensure good handover of care

12
After 3 years..
  • Delayed Recovery 20-25 Long term support
  • Single episode, good recovery 25 Primary
    care
  • Multiple episodes, partial recovery 50 CMHT

13
The transition from pre-morbid phase through
prodrome to first episode psychosis
First episode psychosis
Severity of Symptoms
Prodromal phase
At risk mental state
Time The need for care preceeds capacity for
definitive diagnosis
14
Three key clinical states
The at risk mental state. The prodrome non
specific symptoms. anxiety, depressed mood ,
obsessions.
The critical period (Birchwood,
1998) Disabilities in particular during first 3
years.
15
ON, onset of negative symptoms OP, onset of
psychosis, positive symptoms OT, onset of
treatment
Early Course of Psychosis. (Modified from Larsen
TK et al, Schzophr Bull 1996 22241-256.)
Duration Untreated Psychosis
OT
OP
ON
Premorbid phase Prodromal phase Psychotic
symptoms First treatment Residual symptoms
End of Episode
Episode onset
Illness onset
Illness duration
Psychotic episode duration
16
  • DUP Pathways to Care

First start treatment
Transition to psychosis
First contact health service
Predisposing factors?
First contact any agency
Triggers?
BLIP
DUP
Symptoms
Attenuated Sx.
Psychosis
ProdromeOnset
Features positive symptom hallucinations,
delusional beliefs, thought disordeer. Negative
symptoms avolition, anhedonia, affective
flattenoing, attentional impairment
Features poor concentration/motivation Depression
, anxiety, odd behaviour
Time
17
UK and International EI outcomes Research
  • EarIy Intervention
  • London Mi-Data pan-London research network
  • First Episode Research Network (FERN)
  • EDEN and National EDEN
  • PSYGRID
  • LEO outcome data
  • Early detection
  • EDIE and EDIE2 trial
  • EDIT
  • Burgeoning international evidence base
  • (eg. Addington, 2007, McGorry 2007, OPUS
    outcome data)

18
Association between DUP outcome Early
detection suicide attempts, compliance,
psychosocial outcomes

Long DUP readmission rates,
initial remission

Cochrane database Marshall Lockwood 2006
19
EI services reduce DUP
  • TIPS project (Johannessen) in Stavanger
  • Major public health educational programme
  • Increase help seeking behaviour
  • EPPIC service (McGorry) in Melbourne
  • DUP reduced to 45 days
  • Youth friendly environments

20
  • Compared to standard service
  • Lower DUP
  • More contact at f.u. 18 months
  • Fewer bed days lower use of MHA
  • Significantly fewer relapses at five years
  • Reduction of suicide rate in young
  • Cost effective
  • Better at translating clinical recovery to social
    recovery

21
Paying the Price The cost of mental health care
in England to 2026
McCrone P, Dhanasiri S, Patel A, Knapp M,
Lawton-Smith S Kings Fund 2008
  • Early intervention services for psychosis have
    also demonstrated their effectiveness in helping
    to reduce costs and demands on mental health
    services in the medium to long-term, and should
    be extended to provide care for people as soon as
    their illness emerges.

22
Early Intervention with BME Communities Base
Case Costs (McCrone, Dhanasari, Knapp 2007)
23
Counting costs EI Cost Economic Data (McCrone,
Dhanasari, Knapp 2007)
24
EI Self Assessment Report 2007/08
  • Red (not meeting EI PIG or min fidelity criteria
    providing for lt50 target caseload)

  • 5
  • Amber (meets EI PIG and min fidelity criteria
    providing for 51-90 target caseload)

  • 26
  • Green (meets PIG and min fidelity criteria
    providing for between 91 and 100 caseload)

  • 67

25
EI Self Assessment Report 2007/08 SHA Averages
  • East of England 2.8
  • North West 2.5
  • North East 2.7
  • East Midlands 3
  • London 1.9
  • South West 2.8
  • South East Coast 1.6
  • South Central 3
  • West Midlands 2.6
  • Yorkshire and Humber 2.5
  • Where 1 RED, 2 AMBER, 3 GREEN

26
Future of EI and the EI Programme
  • Threats
  • Uncertainty over the future of NIMHE and
    regional/national EI Lead posts
  • Unlikely to be further EI specific national
    policy drivers
  • National EI Programme seen as very successful and
    a model for national programmes but unlikely to
    continue
  • Strengths
  • Strength and value of EI regional informal
    networks
  • EI in strong position seen to be a solution to
    problems eg. DRE agenda, suicide, offender
    pathways and has demonstrated cost effectiveness
  • EI offers a successful paradigm for early
    detection/ intervention initiatives for other MH
    difficulties

27
Case Study
  • Melissa, 19 years old returned from University.
  • Youngest of three.
  • Became low in mood, couldnt concentrate.
  • Had a trial of A-Ds student counselling.
  • What to do next ?

28
Take a history
  • Three months ago assaulted.
  • Pin prick marks on skin?
  • Requesting second pregnancy test.
  • Began to fall behind in course work.
  • Thinks friends dont like her.
  • Cannabis helps.
  • Denies voices I am not mad!
  • Denies thoughts of DSH.
  • Mother phoned bought a copy of the Koran.
  • We should know about other religions
  • What to do next?

29
A month later..
  • From mother awake at night.
  • Not wanting contact with friends.
  • Mirrors turned around. Doing less and less.
  • From Melissa feeling frightened.
  • Looks preoccupied.
  • Not sure but thinks thoughts are not hers.
  • What to do next ?

30
Yes, call S.T.E.P!!
31
A month later..
  • Carrying Osama Bin Ladens child.
  • Special mission to reconcile East and West.
  • Mood becoming elated.
  • No auditory hallucinations.
  • Reluctantly accepts help low dose atypical.
  • Aunt with schizophrenia history of abuse.
  • Still using cannabis but less.

32
Learning points
  • Adolescent angst depression psychosis.
  • A history needs time.
  • Cannabis complicates life!
  • Voices not necessary.
  • Impaired concentration as 1st presentation.
  • Association with childhood abuse ?
  • Dont forget the family history.
  • A good outcome with full recovery is the aim.



33
Useful web links for EI
hhtp//www.rethink.org hhtp//www.schizophreniagui
delines.co.uk hhtp//www.nimhe.csip.org.uk/home hh
tp//www.iris-initiative.org.uk/ hhtp//www.iepa.o
rg.au/ hhtp//www.eppic.org.au/ hhtp//www.mind.or
g.uk hhtp//www.thorn-cheltenham.org.uk/ hhtp//ww
w.orygen.org.au/
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