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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

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slide2

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
Types of Early Intervention Model
  • Option 1: Basis? (CAMHS, Adult, 1° Care, Youth service)
  • 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
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
slide5

Intervening to Maximise Recovery & Prevent Relapse

Normal development

Early intervention

Prodrome

Functioning

Assertive follow-up

Community Team

First episode

of psychosis

2nd episode

of psychosis

16

20

24

Age

slide6

Optimising Inpatient Care and Treatment in Early Psychosis?

Normal development

Prodrome

Functioning

First episode

of psychosis

2nd episode

of psychosis

FEP

Inpatient

services

16

20

24

Age

slide7

Intervening to reduce the Duration of Untreated Psychosis (DUP)

Normal development

Early intervention

Functioning

Prodrome

First episode

of psychosis

Early detection & Crisis Assessment Team

2nd episode

of psychosis

16

20

24

Age

slide8

Intervening in the Prodrome Phase of Early Psychosis

Prodrome clinic

Normal development

Early intervention

Prodrome

Functioning

First episode

of psychosis

2nd episode

of psychosis

16

20

24

Age

configuration of leo service
Configuration of LEO Service

Primary Care

psychotic

prodromal

OASIS

LEO-CAT

Prodrome

clinic

Early detection & crisis assessment team

2 year follow-up

LEO

Inpatient

Unit

LEO Community Team

slide10

Canada’s Early Intervention Services

  • Newfoundland
  • N&L EPP
  • British Columbia:
  • EP Initiative of British Columbia
  • EPIVMHC,Victoria
  • Vancouver
  • EPIP, White Rock
  • Quebec:
  • Levis
  • Montreal
  • Quebec City
  • Alberta:
  • EPT&PP, Calgary (930,000)
  • Nova Scotia:
  • NSEPP
  • Halifax -
  • Saskatchewan:
  • EIPP, Saskatoon
  • Ontario:
  • PEPP, London
  • FEPP, Toronto
  • Psychotic Disorders U., Hamilton
  • Ottawa FEPP
  • KPP&TP, Kingston
  • Key figures:
  • Jean Addington
  • Bob Zipursky
  • Ashok Malla
  • Lili Kopala
slide11

Early Psychosis Programs in the USA

  • Portland, Maine
  • PIER service (McFarlane)
  • Salem, Oregon:
  • Early Assessment & Support Team (EAST) (pop 600,000) Managed care funded
  • Yale, New Haven:
  • PRIMHE (T. McGlashan)
  • Bethseda, MD:
  • NIMH research:(Wyatt etc)
  • New York:
  • Prodrome (Cornblatt)
  • Pittsburg:
  • EI program (Keshevan)
  • LA California:
  • UCLA (Ventura, Neuchterlien etc)
  • N. Carolina:
  • FEP & prodrome studies (Lieberman)
slide12

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)

.

.

.

.

.

slide13

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
  • EPOES, Fremantle
  • EEPP, Rockingham
  • /Kwinana

.

.

  • ACT:
  • Canberra EI service

.

.

  • South Australia:
  • Noarlunga EP Program
  • Victoria:
  • EPPIC
  • Dandenong
  • EP Program, Alfred Hosp.
  • Central East EP Project
slide14

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)
  • (Each sector has 20 CCU beds for long-stay patients)

21

Western Melbourne

24

EPPIC

16

21

24

South west Area

= Acute adult

= EPPIC beds

overview of mental health services for kids youth
Overview of Mental Health Services For Kids & Youth

Western Region of Melbourne (800,000)

Youth Assessment Team

Prodrome

PACE

Clinic

Non-psychotic

Ages 15 -19

Psychotic

Ages 15-30

Older Adolescent Service

(follow-up to age 19)

EPPIC

(18 month follow-up)

Acute

Inpatient

Care

Day

Group

Program

Family

work

Cognitive

Therapies

Outpatient

Case

Management

Intensive

Outreach

Support

pace treatment trial phillips et al 2000 mcgorry et al 2002 n 59
PACE Treatment Trial(Phillips et al 2000, McGorry et al, 2002)(n= 59)

Transition Rate to Psychosis

  • RCT of CBT + low dose Risperidone X 6/12 versus supportive psychosocial therapy (NSI)
  • Both groups ~ 50% received SSRIs
  • 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)

(N=28)

35.7%

(N=31)

9.7%

P = 0.026 Fisher Exact test

slide17

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)

Palau, Miconesia

(South Africa)

slide18

Swiss Early Psychosis Programs

  • Bern:
  • Uni Hosp. of Social & Comm. Psych.
  • (Gekle) (Merlo - moved to Geneva)

Geneva & Zurich:

Swiss Early Psychosis Project SWEPP (Simon, Umbricht & Merlo)

  • Basil:
  • Uni Hosp. Basil: Basil FEPSY screening study (Gschwandtner et al)
slide19

German Early Psychosis Programs

  • Dusseldorf:
  • RCT of psychological Rx in FEP (Klinberg)

.

.

  • Heidelberg:
  • Heidelberg Early Adolescent & Adult Recognition & Therapy Centre for Psychosis (HEART) EI service since since 1994 (Franz Resch et al)

.

  • Cologne:
  • Cologne early Recognition study (Klosterkotter, Schultze-lutter et al)

.

.

.

  • Bonn:
  • Prodrome Rx (Hambrecht et al)
  • Vienna, Austria:
  • Adolescent EI program at University Hosp. of Vienna (Amminger, Edwards)
  • Mannheim:
  • Central Insitute of Mental Health
  • (Hafner, Maurer et al)
slide20

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)

Control

DUP median (weeks)

slide21

OPUS study

(Nordentoft et al )

RCT of Assertive Community Follow-up in First Episode Psychosis

582 patients (18 - 45 year olds) with non affective first episode psychosis

Mean Bed days/patient

% cases with mod/severe symptoms

(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

slide22

Dutch & Belgian EI Programs

  • Netherlands:
  • Academic Medical Centre (Don Linszen)
  • University of Maastricht: NEMESIS (Van Os, J.)
  • University Med Centre, Utrecht (Dutch Prediction of Psychosis Study- DUPS)
  • Belgian Projects:
  • PECC (Janssen-Cilag)
  • 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
slide23

Early Intervention Services in England

  • Edinburgh
  • YPU @ Royal Edinburgh Hosp.
  • Edinburgh High Risk study(E. Johnstone)
  • Glasgow:
  • EI service (A Blair)
  • NHS plan: PIG
  • IRIS: Newcastle declaration
  • 50 teams by 2005
  • -23 EI teams to date
  • EI teams include:
  • North Birmingham EI service
  • LEO & OASIS service
  • Plymouth service
  • Manchester
  • Tower Hamlets
  • ETHOS
  • COAST
  • Sheffield EI service
  • STEPS, Poole

£1M

rct of leo community team engagement with services at 18 months n 138
RCT of LEO Community Team Engagement with Services at 18 months (N=138)

% Clients still attending at 18 months

At 6 months:

African Caribbean engagement:

= 89% vs 27 %:

LEO vs Control

p<0.02

(Craig et al, 2004)

adherence to prescribed antipsychotic medication over 6 months
Adherence to prescribed antipsychotic medication over 6 months

1

Proportion taking medication

0.61

LEO

0.5

0.28

OTHER

0

1

3

4

5

6

2

Months post randomisation

(Craig et al, 2004)

leo trial results relapse at 18 months from full or partial recovery n 122
LEO Trial ResultsRelapse at 18 months, from full or partial recovery (N=122)
  • Significant better improvements @ 18 months follow-up::
  • Positive and Negative symptoms
  • Insight & treatment adherence
  • GAF score
  • Satisfaction with services

% of clients who relapsed

p<0.05

(Craig, Garety et al, 2004)

hospitalisation rates for leo patients
Hospitalisation rates for LEO patients

LEO Ward opens

(n=73)

(n=71)

(n=63)

(n=73)

(n=156)

Control group (standard care)

LEO Trial Group

Inter study LEO group

% LEO patients admitted

1st LEOCAT

LEOCAT Trial

2000 - 2001 - 2003 - 2004-2005

discharges destinations after 2 years follow up with leo
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
  • 20 additional clients overdue discharge
    • 14 waiting CMHT transfer
slide29
Economic Benefits of Intervening Early:Comparison of LEO vs. Estimate of Standard Costs in First Episode Psychosis(2003 figures)

* Based on ratios from Agustench & Cabases (2000), estimates by Guest & Cookson (1999) and adjusting for 3% inflation for 2003

NHS Cost per first episode patient/year

Total standard NHS cost(estimate)

Total = £26,851 over 2 years

LEO costs (including LEOCAT):

Total of £15,985 over 2 years

Savings with LEO = £10,866 (40.4% less than standard NHS costs)