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Early Intervention:
The International Perspective
Paddy Power
“A Stitch in Time Saves Nine”
Development of Early Psychosis Programs
Melbourne, mid-80’s
Buckinghamshire, mid-80’s
North Birmingham UK early 90’s
Germany, 1990’s (research1970’s)
USA & Canada, early 90’s
Scandinavia, mid-90s
Switzerland mid - 90s
Amsterdam, late 90’s
Australia late 90’s
UK 1999/2000
Far East & South East Asia, 2001
Networks: IEPA & European FE Schizophrenia Network
Types of Early Intervention Model
• Option 1: Basis? (CAMHS, Adult, 1° Care, Youth service)
Gallery Image 34 of
191
• Option 2: Service model? (Specialist vs generic)
– Specialist EI services
•
•
•
•
Stand alone EI service
Hub and Spoke model
Piggy-back supplementary EI model
Tertiary consultation EI services/clinic
– Generic Based Services
• Top up with embedded EI worker/s
• Top up with EI training and clinical guidelines
– Research based interventions
• Option 3: Degree of community integration
– Public health promotion campaigns
– integration with social services, education, employment, housing, A&D
services, service user agencies
Aims of an Early Intervention service
• Reduce delays (& DUP) by:
– promoting early detection and
collaborative engagement in the community
• Optimise assessment & diagnosis by:
– Comprehensive Bio/psycho/social assessment
• Maximise recovery by:
– providing integrated bio/psycho/social community Rx
– focus on functional as well as symptomatic factors
– addressing co-morbidity and treatment resistance early
• Prevent relapse by:
– ensuring assertive followup and psychoed. during critical period
Intervening to Maximise Recovery &
Prevent Relapse
First episode
of psychosis
16
Age
20
2nd episode
of psychosis
24
Optimising Inpatient Care and Treatment
in Early Psychosis?
First episode
of psychosis
16
FEP
Inpatient
20
services
Age
2nd episode
of psychosis
24
Intervening to reduce the Duration of
Untreated Psychosis (DUP)
First episode
of psychosis
2nd episode
of psychosis
16
Age
20
24
Intervening in the Prodrome Phase of
Early Psychosis
First episode
of psychosis
16
Age
20
2nd episode
of psychosis
24
Configuration of LEO Service
Primary Care
psychotic
prodromal
LEO-CAT
OASIS
Prodrome
clinic
Early detection & crisis
assessment team
LEO
Community
Team
LEO
Inpatient
Unit
Canada’s Early Intervention Services
Newfoundland
British Columbia:
•EP Initiative of British Columbia
•EPIVMHC,Victoria Alberta:
•Vancouver
•EPT&PP, Calgary (930,000)
•EPIP, White Rock
Saskatchewan:
•EIPP, Saskatoon
Key figures:
•Jean Addington
•Bob Zipursky
•Ashok Malla
•Lili Kopala
•N&L EPP
Quebec:
Nova Scotia:
•Levis
•NSEPP
•Montreal
•Quebec City •Halifax -
Ontario:
•PEPP, London
•FEPP, Toronto
•Psychotic Disorders U., Hamilton
•Ottawa FEPP
•KPP&TP, Kingston
Early Psychosis Programs in the USA
Portland, Maine
Salem, Oregon:
•Early Assessment & Support Team (EAST)
(pop 600,000) Managed care funded
•PIER service (McFarlane)
Yale, New Haven:
•PRIMHE (T. McGlashan)
Bethseda, MD:
•NIMH research:(Wyatt etc)
New York:
•Prodrome (Cornblatt)
Pittsburg:
LA California:
•EI program (Keshevan)
•UCLA (Ventura, Neuchterlien etc)
N. Carolina:
•FEP & prodrome studies
(Lieberman)
New Zealand’s
Early Intervention Services
New Zealand National Early Intervention Group
• Auckland: EPI Centre, Kari Centre, Taylor Centre, Manaaki CMHT
- FEP, St Lukes FEP, Hartford House EPI, Campbell team Lodge EI
.
team
.
...
•Wellington: Wellington EI service (400,000)
•Christchurch: Tatara House EIP service (380,000)
•Dunedin: Aspiring House EI service (150,000)
Early Psychosis Programs in Australia
National Early Psychosis Project (based at EPPIC)
Queensland:
•Uni of Brisbane studies
New South Wales:
•YPPI service, Gosford
•EP program, Marouba
•EP program, North Sydney
•EPIP-SWAHS, Liverpool
•EPIC, Penrith
•Western Sydney FEPP
.
Western Australia:
.
•First Psychosis Liaison Unit,
Bentley
South Australia:
•EPOES, Fremantle
•Noarlunga EP Program
•EEPP, Rockingham
/Kwinana
.
.
.
.
ACT:
.
•Canberra EI service
Victoria:
•EPPIC
•Dandenong
•EP Program, Alfred Hosp.
•Central East EP Project
EPPIC service
Western Region of Melbourne (pop = 850,000)
4 sectors
•Inner West: (145,000)
•North West: (266,700)
•Mid west: (208,000)
•South West: (237,600)
21
(Each sector has 20 CCU
beds for long-stay patients)
24
EPPIC
16
21
24
South west
Area
= Acute adult
= EPPIC beds
Overview of
Mental Health Services For Kids & Youth
Western Region of Melbourne (800,000)
Youth Assessment Team
Prodrome
PACE
Clinic
Psychotic
Ages 15-30
Non-psychotic
Ages 15 -19
EPPIC
(18 month follow-up)
Older Adolescent Service
(follow-up to age 19)
Outpatient
Case
Management
Intensive
Outreach
Support
Acute
Inpatient
Care
Day
Group
Program
Family
work
Cognitive
Therapies
PACE Treatment Trial
(Phillips et al 2000, McGorry et al, 2002)
(n= 59)
Transition Rate to Psychosis
• RCT of CBT + low dose
40%
Risperidone X 6/12 versus
(N=28)
supportive psychosocial therapy
35%
(NSI)
30%
35.7%
25%
20%
15%
10%
5%
0%
NSI • Both groups ~ 50% received
SSRIs
(N=31)
9.7%
after 6 months
treatment
P = 0.026 Fisher Exact test
Risp. +
CBT
• Those fully compliant with
Risperidone afforded greatest
protection at 6 months (5.6%) and
follow-up after meds ceased
• 2 suicides in refusal group (n=33)
South East Asian Early Psychosis Network
South Korea
Tokyo, Osaka
Hong Kong: EASY
- 4 teams cover 7M
(Eric Chen et al)
Singapore:
EPIP
1 team covers 4 M
(S. Chong et al)
(South Africa)
Palau,
Miconesia
Swiss Early Psychosis Programs
Bern:
•Uni Hosp. of Social & Comm. Psych.
(Gekle) (Merlo - moved to Geneva)
Basil:
•Uni Hosp. Basil: Basil FEPSY screening
study (Gschwandtner et al)
Geneva & Zurich:
Swiss Early Psychosis Project SWEPP
(Simon, Umbricht & Merlo)
German Early Psychosis Programs
Dusseldorf:
•RCT of psychological Rx in FEP
(Klinberg)
Cologne:
•Cologne early Recognition study
(Klosterkotter, Schultze-lutter et al)
Bonn:
...
•Prodrome Rx (Hambrecht et al)
Mannheim:
•Central Insitute of Mental Health
(Hafner, Maurer et al)
Heidelberg:
•Heidelberg Early Adolescent & Adult
Recognition & Therapy Centre for
Psychosis (HEART) EI service since
since 1994 (Franz Resch et al)
.
Vienna, Austria:
•Adolescent EI program at University
Hosp. of Vienna (Amminger, Edwards)
Scandinavian Early Psychosis Services
Finland:
•Turku: Detection of early
Psychosis project
(Suomela et al)
Norwegian Services:
•TIPS - Roskilde/Stravanger
(Larsen, Johannessen etc)
•UNA-projektet, Oslo
•EOP, Skien
Swedish Services:
•Parachute Project (1.5 M), Stockholm
•Sodertalja Psykiatriska Sektor, Sodetalje
•TUPP Project, Stockholm (Cleland)
16
14
12
10
8
6
4
2
0
Early detection
Standard
DUP (median in weeks)
OPUS study
582 patients (18 - 45 year olds) with non affective first episode psychosis
35%
Standard teams
Early Intervention team
30%
Mean Bed days/patient
% cases with mod/severe symptoms
(Nordentoft et al )
RCT of Assertive Community Follow-up in First Episode Psychosis
25%
20%
15%
10%
5%
0%
Psychotic Sx 2
years
-ve Sx 2 years
90
80
70
60
50
40
Standard teams
Early Intervention team
30
20
10
0
Bed days in 1st year
(p <0.05)
The cost saved for in-patient care/year = €600,000 for 100 patients = wages of 10 staff
Merete Nordentoft, Bispebjerg Hospital, Department of Psychiatry, 2004
Dutch & Belgian EI Programs
Netherlands:
Belgian Projects:
•PECC (Janssen-Cilag)
•Academic Medical Centre (Don Linszen)
•University of Maastricht: NEMESIS (Van
Os, J.)
•University Med Centre, Utrecht (Dutch
Prediction of Psychosis Study- DUPS)
Other European Projects:
•European Prediction of Psychosis (EPOS) study (6 centres: Birmingham,
Amsterdam, Cologne, Turku, Santander, Dannstadt)
•Dublin: SJOG Hospital (E. O’Callaghan)
•Bordeaux: (Helen Verdoux)
•Barcelona, Madrid, Santander: 4 prodrome research programs
•Lisbon: planning EI service
•Eastern European, Russian & Middle East: research programs & plans for services
Early Intervention Services in England
Edinburgh
Glasgow:
•YPU @ Royal Edinburgh Hosp.
•EI service (A Blair)
•Edinburgh High Risk study(E.
Johnstone)
•NHS plan: PIG
•IRIS: Newcastle
declaration
EI teams include:
•North Birmingham EI service
•LEO & OASIS service
•Plymouth service
•Manchester
•Tower Hamlets
•ETHOS
•COAST
•Sheffield EI service
•STEPS, Poole
•50 teams by 2005
-23 EI teams to date
£1M
% Clients still attending at 18 months
RCT of LEO Community Team
Engagement with Services at 18 months
(N=138)
90%
80%
70%
60%
50%
LEO
Control
40%
30%
20%
At 6 months:
10%
African Caribbean
engagement:
= 89% vs 27 %:
LEO vs Control
0%
In contact
with services
(Craig et al, 2004)
In hospital
p<0.02
Lost to
contact
Proportion taking medication
Adherence to prescribed antipsychotic
medication over 6 months
1
0.5
0
1
3
4
5
6
2
Months post randomisation
(Craig et al, 2004)
0.61
LEO
0.28
OTHER
LEO Trial Results
% of clients who relapsed
Relapse at 18 months, from full or partial recovery
(N=122)
LEO
Control
50%
40%
Significant better improvements @
18 months follow-up::
30%
• Positive and Negative symptoms
20%
• Insight & treatment adherence
10%
• GAF score
• Satisfaction with services
0%
p<0.05
(Craig, Garety et al, 2004)
Hospitalisation rates for LEO patients
LEO Ward opens
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Control Group
(n=73)(n=71)
(n=63)
(n=73)
(n=156)
%2000
LEO
patients
- 2001
- 2003 - admitted
2004-2005
LEO Trial Rx. group
Inter trials group
1st LEO CAT group
LEOCAT trial
Discharges Destinations after 2 years
Follow-up with LEO
(n=269)
136 LEO clients discharged to date:
• 37 to Out of Area services
– 17 overseas
Private
3%
OPD
12%
GP
39%
CMHT
32%
Lost
10%
20 additional clients overdue discharge
–14 waiting CMHT transfer
Died
1%
Prison
2%
Rehab
1%
NHS Cost per first episode patient/year
Economic Benefits of Intervening Early:
Comparison of LEO vs. Estimate of Standard Costs
in First Episode Psychosis
(2003 figures)
CMHT's costs
£25,000
£20,000
£8,951
Hospital costs
£15,000
£10,000
£5,000
* Based on ratios from Agustench & Cabases
(2000), estimates by Guest & Cookson (1999)
and adjusting for 3% inflation for 2003
£7,033
Total standard NHS cost (estimate)
£8,323
LEO costs (including LEOCAT):
£18,527
Total = £26,851 over 2 years
Total of £15,985 over 2 years
£Standard NHS LEO service
services
Savings with LEO = £10,866 (40.4% less than standard NHS costs)