Transcript Schizophrenia and other Psychosis

Devon Partnership
NHS Trust
Early Intervention in Psychosis
Dr Charles Montgomery
Consultant Psychiatrist
Specialist Team for Early Psychosis
“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 people’s 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)
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:
1.
Early detection of psychosis
2.
Reduce the long duration of untreated psychosis
3.
Importance of the first 3-5 years following onset (critical
period) for later biological, psychological and social
outcomes
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
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 people’s inpatient care and crisis provision
 Youth sensitive service provision
 Extend the EI Paradigm to other mental health disorders that
have their onset in youth
IMPROVE
ACCESS &
RAISE COMMUNITY
AWARENESS
ENGAGEMENT
EARLY PSYCHOSIS
DECLARATION
INTEGRATED
HEALTHCARE
PROMOTE
RECOVERY AND
ORDINARY LIVES
ENGAGE AND
SUPPORT
FAMILIES
90% of affected individuals report
satisfaction with their employment,
educational and social attainments
Duration of Untreated
Psychosis is less than 3
months on average
The use of involuntary
treatment should be less
than 25%
Suicide rates in the first two
years after diagnosis are
less than 1%
“TRANSFORMATIONAL
OUTCOMES”
90% of families feel respected
and valued as partners in care
All 15 year olds are educated
to understand and deal with
psychosis.
All generalist and specialist health and social
care practitioners know how to deal
effectively with early psychosis
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
1.
2.
3.
4.
5.
6.
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
Early Intervention Provision
(15,750 cases at end of March 08)
25000
20000
15000
LDPR
10000
5000
0
1998
2002/3
2003/4
2 teams
24 teams
41teams
2004/5
2005/6
2006/7
2007/8
2008/9?
109 teams 127 teams 160 teams 145services
What we do….
5% self referral
 55% from Primary care
 15% other agencies
 25% wards
 Contact within 48 hrs
 Assessment within 7 days
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3- 6 month assessment
 assertive engagement
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Support for 3 years (low case loads)
F.E.P.
Age 14-35
Earlier AND better
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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
After 3 years…..
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Delayed Recovery : 20-25 %
Long term support
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Single episode, good recovery : 25%
Primary care
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Multiple episodes, partial recovery : 50%
CMHT
Severity of Symptoms
The transition from pre-morbid phase through prodrome to first episode psychosis
First episode psychosis
Prodromal phase
At risk mental state
Time
The need for care preceeds capacity for definitive diagnosis
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.
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; 22:241-256.)
Duration Untreated Psychosis
OT
OP
ON
Premorbid phase Prodromal phase Psychotic symptoms First treatment Residual symptoms
Illness onset
Episode onset
Illness duration
Psychotic episode duration
End of Episode
DUP & Pathways to Care
First start treatment
Transition
Transition
to psychosis
psychosis
to
First contact health service
Symptoms
Predisposing
factors?
Triggers?
First contact any
agency
BLIP
DUP
Attenuated Sx.
Psychosis
Prodrome
Onset
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
UK and International EI outcomes Research
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EarIy Intervention:
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Early detection:
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London Mi-Data pan-London research network
First Episode Research Network (FERN)
EDEN and National EDEN
PSYGRID
LEO outcome data
EDIE and EDIE2 trial
EDIT
Burgeoning international evidence base:
(eg. Addington, 2007, McGorry 2007, OPUS outcome data)
Association between DUP & outcome
Early detection :
Long DUP :
suicide attempts,
compliance,
readmission rates,
psychosocial outcomes
initial remission
Cochrane database : Marshall & Lockwood 2006
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
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
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.”
Early Intervention with BME Communities: Base
Case Costs (McCrone, Dhanasari, Knapp 2007)
70000
£61701
60000
Cost (£s)
50000
£37510
40000
30000
20000
£21006
£13045
10000
0
1-year
3-year
EI
SC
Counting costs…
EI Cost Economic Data
(McCrone, Dhanasari, Knapp 2007)
50000
Expected costs (£)
40811
30000
26568
14394
10000
9422
One year costs
-10000
EI
Standard care
Three year costs
EI Self Assessment Report 2007/08
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Red (not meeting EI PIG or min fidelity criteria
providing for <50% 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%
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
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
Case Study
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Melissa, 19 years old returned from University.
Youngest of three.
Became low in mood, couldn’t concentrate.
Had a trial of A-D’s & student counselling.
What to do next ?
Take a history
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Three months ago assaulted.
Pin prick marks on skin…?
Requesting second pregnancy test.
Began to fall behind in course work.
Thinks friends don’t 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?
A month later…..
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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 ?
Yes, call S.T.E.P!!
A month later…..
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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.
Learning points :
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Adolescent angst
depression
psychosis.
A history needs time….
Cannabis complicates life!
“Voices” not necessary.
Impaired concentration as 1st presentation.
Association with childhood abuse ?
Don’t forget the family history.
A good outcome with full recovery is the aim.
Useful web links for EI :
hhtp://www.rethink.org
hhtp://www.schizophreniaguidelines.co.uk
hhtp://www.nimhe.csip.org.uk/home
hhtp://www.iris-initiative.org.uk/
hhtp://www.iepa.org.au/
hhtp://www.eppic.org.au/
hhtp://www.mind.org.uk
hhtp://www.thorn-cheltenham.org.uk/
hhtp://www.orygen.org.au/