Transcript An Ideal 'At-Risk' Service

Key Activities of an ARMS
Service
Dr Samantha Bowe
Clinical Psychologist / Clinical Lead for EDIT
Services
BSTMH NHS Trust
Acknowledgements
 Salford EDIT Team
Dr Sophie Parker
Clinical Psychologist
Maria Kaltsi
Assistant Psychologist
Rory Byrne
Service User Representative
Sarah Ford
Assistant Psychologist
Jane Foster
PA/ Team Secretary
 Dr Paul French / Prof Tony Morrison
Associate Directors in Early Intervention
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
19.7.02
19.7.02
Primary Care Guidelines for Identification of Suspected or First Episode Psychosis
Checklist for Psychosis
Scoring
If physical signs consider
The family is concerned
Excess use of alcohol
Use of street drugs (including cannabis)
Arguing with friends and family
Spending more time alone
………… One point each
…………….
____
____
____
____
____
Sub Total ____
Sleep difficulties
Poor appetite
Depressive mood
Poor concentration
Restlessness
Tension or nervousness
Less pleasure from things
………… Two points each ………….
____
____
____
____
____
____
____
TWENTY POINTS OR MORE CONSIDER
REFERRAL
FOR ASSESSMENT .
Systemic infection
Nutritional deficiencies
CNS abnormalities
Metabolic disorders
Cardiac abnormalities
____
____
Drug toxicity
EDIT
Sub Total ____
Ideas of reference *
Odd beliefs *
Odd manner of thinking or speech
Inappropriate affect
Odd behaviour or appearance
First degree family history of psychosis
plus increased stress or deterioration in
functioning *
………… Five points each …………...
Liver function abnormalities
Sub Total ____
Feeling people are watching you *
Feeling or hearing things that others cannot *
………… Three points each …………
Substance abuse
____
____
____
____
____
____
Sub-threshold/uncertain
diagnosis
EI team
Clearly first episode
psychosis
Sub Total ____
Final Total
If any * items are
endorsed then consider
referral to EDIT even if
score is less than 20
0161 772 4350
0161 745 2254
CMHT
If immediate risk
Crisis Team
Referral Pathways
Referral Source
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
Family
CAMHS
Assertive Outreach
No. Referred
26
19
17
7
7
7
6
5
4
4
2
2
2
1
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
Evidence Based Interventions
 Cognitive Therapy
 Effective at preventing transition to psychosis
 Transition rates (12 months post CT): cognitive
therapy: 6%
monitoring alone: 22%
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.
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
Drop Out Rates
60
% of dropouts
50
40
30
20
10
0
PACE
EDIE
PRIME
McGorry et al. 2002
Morrison et al. 2004
McGlashan et al. 2006
[CBT plus risperidone]
[CT]
[Olanzapine]
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.
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
Transition rates: olanzapine = 16 %
placebo = 37%
 Side effects / ethical issues
 If not effective, less compliance if make transition?
 Follow International Clinical Practice Guidelines
for Early Psychosis (2005)
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
Monitoring
 Regularly repeat assessment measures
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.
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
Service User Involvement
 Service user feedback
 EDIT: Service User Representative –
consultancy role on service development
- interview panel for recruitment
- service user forum / research
- someone clients to speak to when deciding
whether or not to be seen for assessment or
therapy
Interface with Services
 Ensure effective interface between services
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
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
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
Core Principles
 Culture, age & gender sensitive
- 66% clients in EDIT under 21 yrs
 Service user & family focused
- collaborative approach, individually tailored, based on clients’
‘problem list’ & goals
- 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.
Core Principles
 Low use of stigmatising settings
(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)
- Service delivery in primary care setting (EDIT & GP)
unless significant risk issues which require co-working with
other services
 Recovery based principles:
- meaningful activities
- valid social roles (college, work, relationships)
Summary: Core Features
Prevent
Transition to
Psychosis
ARMS
Service
Raise
Awareness /
Education
Stigma
Reduce
DUP
Summary: Core Features
Specialist
Assessment
Evidence
Based
Interventions
Family
Involvement
ARMS client
Case
Management
Monitoring
Up to 3 years
Summary: Core Features
Recovery
Focused
PIG
Compliant
ARMS Service
Primary Care
Setting
Good
Interface with
Other
Services
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”.
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’
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’
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’
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.
Contact Details
[email protected]
Dr Samantha Bowe
Clinical Psychologist / Clinical Lead for EDIT Services
0161 772 4350