Transcript Document

Earlier intervention in psychosis
- everybody’s business
A primary
care view
Dr David Shiers
Dr Jo Smith
Joint leads NIMHE
National EI Programme
Haugesund. Workshop on primary care. Sept 2nd 2008
Learning objectives
 Explore the interface between
psychiatry and primary care
 Develop a marketing strategy to ‘sell’
early intervention to primary care
colleagues
Average GP (list 1800) sees each yr:
– 250 new mental health cases
– 5 with severe mental health problems
– 1 with a first episode of psychosis
At any one time is responsible for:
– 10-20 registered on his/her list with psychosis
– 30-50% without any support from specialist care
(Kendrick,2000)
Context:
– Knowledge of individual before onset of
psychosis
– Family practice
Continuity
– Alertness to changes in behaviour and functioning which may
precede first episode and relapse
– Potential for better physical health care
Care setting
– More accessible and less stigmatising
Some GP views:
“I know that I cannot look after people with
severe and enduring mental health problems. I do
not have the skills or the knowledge. I couldn't do it
well"
“Sometimes they have to be standing on a
bridge before we can get people help and we have
to exaggerate symptoms to get the psychiatrist’s
attention at an earlier stage”
Helen Lester BMJ 2005
Contrasting with patients’ views typified by:
"I mean, the GP has to have some
understanding of mental health but I don't expect
my GP to know all of the issues to do with my
illness...
...I would though expect him or her to refer me
to a specialist person. The important thing is that
somebody is looking after you so it's not just you
on your own.”
Helen Lester BMJ 2005
GPs see a FEP at an age when other
serious mental disorders tend to develop
Victoria (Aus) Burden of Disease Study: Incident Years Lived with
Disability rates per 1000 population by mental disorder
Pathways to Care Audit Data
and GP Survey
 North Staffs Pathways to Care prospective audit n = 45
(Macmillan, Ryles, Shiers & Lee 1998/9)
 Sandwell GP interview n = 3 (Alderton 2000 )
 Worcester Pathways to Care retrospective audit n = 30
and GP workshop n = 26 (Smith 2000)
 Walsall Pathways to Care review from case notes n = 18
(Rayne 2002)
 Gloucester GP Postal questionnaire n = 15 (Davis 2002)
Who are they?
 50% < 24; youngest aged 13
 Average age at onset = 21
 75% live with parent(s) or
spouse
 41% are employed or in fulltime education
Pathway players (n = 45)
General psychiatrists
Family members
GP
Police
CPN
A&E
SW
Psychologist
Teacher / Tutor
Neighbour
Police surgeon
Hostel staff
Probation officer
Prison staff
Resource centre
45
37
36
22
18
13
11
5
4
4
4
4
3
3
3
Health visitor
Work colleagues
Private landlord
Church
Occupational health
Friends
OT
General physician
Learning diff psychiat
Forensic psychiatrist
Substance misuse
Homeless services
Solicitor
Ambulance services
Public Health
3
3
2
2
2
2
2
1
1
1
1
1
1
1
1
Symptoms presented to GPs?
 7% - clear evidence of
psychosis
 37% - physical / somatic
symptoms
 50% report emotional and
psychological changes
 25% report changes in work
and social functioning
Nature of their help-seeking to GP?
 Prodrome: typically 2 – 6 m
 ~ 50% seek help <2 wks of
psychotic symptoms
 ~ 20% of individuals have
courage to seek help themselves
 ~75% relied on family members
to seek help on their behalf
 5 contacts on average to achieve
pathway to care
 GPs are first point of
professional contact ~ 65%
DANGER AHEAD!!!
Pressure wave- trapped
 7-15m treatment delays
 Families’ concerns ignored
 Crisis response is the rule
– 73–80% hospitalised
– 36–59% Mental Health Act
– 45% police involved
 Lifetime suicide risk 10%
– 2/3 within first 5yrs
– around the FEP
 50% disengage: likely crisis
reengagement
Some get marooned…
“…our overwhelming feeling was of an
opportunity missed - to what degree she
has been needlessly disabled by those
first four years of care we’ll never know”
Mother 2002
Stagnation in a ghetto of
disability
Relapse and remission
“…can’t get a job, can’t get a
girlfriend, can’t get a telly, can’t
get nothing… it’s just everything
falls down into a big pit and you
can’t get out…”
Hirschfeld, 2002
Path to social exclusion
and health inequality?
... a path to inequality
 Excluded


12% with a job
In previous 2 weeks (Nithsdale survey)
o 39% either had no friends or had met none
o 34% had not gone out socially
o 50% no interest or hobby other than TV


one in four have serious rent arrears
3x divorce rate
 Dis-ease  up to 25 years less life

33% suicide and injury
 66% premature deaths from physical disorders
Eg. Deaths due to coronary heart disease: kills more than two-thirds of people with
schizophrenia, compared with about a half in the general population,
Accounted for by excess smoking; obesity; hypertension; diabetes
Antipsychotics – link with obesity, diabetes (up to 5x rate)
Lifestyle issues – poverty, diet, exercise, smoking (2x rate)
Poorer health care – poor access to physical health services; discrimination; diagnostic
overshadowing
That’s the problem we
are trying to solve
What do young people and families need?
Optimism
Confidence in a whole systems response to their helpseeking
Earlier detection
– of psychosis
– of ‘at risk mental state’?
Specialist services that
–
–
–
–
‘do psychosis’ as well as ‘do young people’
pre-empt crisis; offer less traumatic ‘first engagements’
offer age / phase specific care in ‘critical period’ of first 3-5 yrs
provide recovery oriented services from the start
Support for families
What do specialist services need
from primary care?
GPs as key pathway players to:
– Listen for and act on family concerns
– Be aware of key indicators
– Be flexible and accessible to promote helpseeking of these young people
– Involve EIS at the earliest opportunity
– Organise care to meet physical health need
What does primary care need from
specialist services?
Youth friendly approach – ban outpatient clinics!
Low threshold of access to specialist advice
– MH assessment of those with suspected FEP
– Monitoring / review of those deemed at ‘high risk’ of FEP
– Individual support for FEP
Collaborative approach
– Clear pathways (e.g. for those aged 14-18; for those with
co-morbid drug misuse)
– Relapse planning
– Planned exit from EIS
Marketing EI to primary care?
Colin’s journey
Rapids
PC
Eddy
Distressed
Family
crisis
Family
Youth
worker
Isolated from
friends
Drop out
of Educ’n
Suicide
attempt
Offending
behaviour
Mental
illness
Rapids
Drugs
No job
Homeless
Rapids
No money
Using Nature – Eddies
Early detection of danger ahead
 Pull ashore, get out,
take a look and regroup
 Use understanding of
the nature of the
journey and knowledge
to stop and even regain
some ground
Family
Eddy
Guides
White water
Rapids
Lookout with
life ring
Safety raft
Supporting GPs’
to do a difficult
job better:
Early intervention is
everybody’s business
 EI services insufficient by
themselves
Equipped for the life ahead both for
the young person and their family
 GPs offer continuity, context
and family practice:
– Key role in care pathway of those with
emerging psychosis
– Ability to listen and act on concerns
of the family
– In it for the long term
– EI for bodies as well as minds
Acknowledgements to:
Dr. Roy Morris Dunedin and Dr
Maryanne Freer, Newcastle for
contributing the white water rafting
metaphor
and to Guzer.com for the images
Thank you
[email protected]
[email protected]
www.earlydetection.csip.org.uk