EARLY INTERVENTION IN PSYCHOSIS

1. EARLY INTERVENTION IN PSYCHOSIS STEP (Specialist team in early psychosis) South and West Devon Dr. Catherine Paton Specialist Registrar (ST5) in General Adult Psychiatry

2. What we will cover today • History • Development of EIT services • Concept – what EIT aim to do • Duration of Untreated Psychosis • Barriers to early intervention • Components of the model • What should EIT look like • Cost impact • Eleanor’s story • CASC practise

3. What do you already know?

4. “The psychiatrist sees too many end states and deals professionally with too few of the pre-psychotic…I feel certain that many incipient cases might be arrested before the efficient contact with reality is completely suspended, and a long stay in institutions made necessary.” (Harry Stack Sullivan , 1927.)

5. History • Not a new idea. • Harry Sullivan (1927) challenged Kraeplin’s ‘dementia praecox’ (1896) as a single disease entity (schizophrenia) with a universally poor outcome. • 60 years would elapse before treatment delay became firmly linked to outcome. • Northwick Park study (Johnstone et al 1986) > 1 year to access services, 3x more relapse in the next 2 years. • First UK EI service = North Birmingham EI service (1989)

6. Development of EI services 1990s: • Growing evidence base • Heightened political sensitivity ( by media concerns for public safety) • Criticism of the traditional ‘one size fits all’ CMHTs.

7. The public’s perception of Psychosis….

8. Formation of new ‘functionalised’ teams with discrete functions to deliver more intensive and focussed support at key points to break the cycle of crisis response and hospitalisation. (NSF 1999, MH-PIG DoH 2001) • Home treatment/crisis response team • Assertive outreach team • Early Intervention : Intensive case management using age- and phase-specific interventions in early phase of psychosis. • 1998: 2 teams 2008/09 :145 teams

9. Concept of Early Intervention 3 main concepts: • Early detection • Reduction in the duration of untreated psychosis • Importance of critical period in outcomes

10. 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.

11. Components of the EI model Early Psychosis Treatment teams Early detection function Prodrome Clinics

12. Duration of untreated psychosis • Mean DUP of 2 years; median DUP within 6 months • Within the DUP, young people experience paranoia, hearing voices, unusual ideas leading to social withdrawal, change in behaviour and increased risk of self harm. • DoH(2002) target: Reduction of DUP or treatment delay as a national priority, setting a median target of 3 months with no delay to extend beyond 6 months (also supported by Early psychosis declaration 2005)

13. Why does DUP matter ? • longer the DUP poorer outcomes In terms of symptoms, quality of life social functioning • 1 in 10 with SMI commits suicide 2/3 deaths occurs within the first 5 years (Wiersma et al 1998)

14. Barriers to Early Identification • Presentations not always clear cut • Poor premorbid functioning-poor social networks, confused with on-going difficulties. • Gradual onset-confusion with depression/ social phobia/anxiety • Onset during ‘normal’ adolescence. • Poor Family/friends support i.e. FHx of admission contributes to longer DUP ( Verdoux et al 1998)

15. The pivotal role for primary care in reducing DUP • Most people who have psychosis live in the community and are registered with a GP • 30-50 % of people with SMI are seen only in primary care setting ( Jenkins et al 2002) • Most GPs see 1 or 2 new cases each year (Skeate et al 2002) and are the most common final referral agent. • We both share a number of philosophical and clinical concerns-low threshold for referral, work with diagnostic uncertainty, work with families • We need a high index of suspicion and a low threshold of referring a young person to the STEP team

16. Working with diagnostic uncertainty in First Episode Psychosis (FEP) • Psychosis is purely descriptive/’umbrella term’-makes no assumption about the cause and does not leap to conclusions about the long term outcomes. • Interventions based on symptoms rather than diagnosis, less stigmatising ( Bentall 1990) • 5.5.% population reported psychotic symptoms in the absence of a psychotic illness • Normal development often includes an overactive imagination that can be mistaken for hallucinations and delusions. • The concept of hearing voices can be confused with experiencing memories or thinking to oneself. • Diagnosis should not be made until a clear clinical picture has emerged. Must try and generate optimism and expectations of positive outcomes.

17. Policy support • EI has enjoyed a sustained policy platform for the last 10 years and continues to hold the attention of policy makers e.g.: NSF-MH 1999, NHS Plan 2000, NICE 2002;2009 EI Recovery plan DoH 2007

18. What should EIT look like… • 14 - 35 year age entry criteria • First three years of psychotic illness • Aim to reduce the duration of untreated psychosis to less than 3 months • Maximum caseload ratio of 1 care coordinator to 10–15 clients • For every 250,000 (depending on population characteristics), one team • Total caseload 120 to 150 • 1.5 doctors per team • Other specialist staff to provide specific evidence based interventions

19. What STEP offer locally (South and West Devon) • 15-35 year • Creative engagement process with assertive follow up • Low dose atypical antipsychotic treatment 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

20. Conditions included… • F 1x.5 • F 20 -29 • F 30 • F 31.2

21. Drug induced psychosis • Association between street drugs and psychosis is particularly confusing. • Substance misuse is common in people with FEP • Frequent use of cannabis increases the risk of psychotic symptoms and that cannabis may account for 10 % of psychotic illnesses. ( Fergusson et al 2006, BMJ) • 25-40% with DIP had non-drug related psychosis in a year/within 3 years (Canton et al 2005;Arendt et al 2005) • Risk ↑ amongst: young ♂ FHx poor premorbid functioning less insight.

22. Role of medication • Patients with FEP responds differently to medication than more established cases with more increased rates of response and increased risk of side effects. • Medication often regarded by the young person as incompatible with everyday life and in their journey to recovery • Initial experience of medication very influential on longer term attitudes and compliance. • Poor/partial compliance could be as high as 80% in SCZ

23. Outcomes • In a recent study, 50% of people with FEP were well enough to discontinue medication at 1 year. • Over the next 18 months, 40 % of those were able to successfully stay off the medication (Wunderink et al 2007)

24. Relapse prevention • Relapse rates around 40 to 60 % during the first year off meds. (Remington 1995) • Relapse rates higher at 2 years and over the 5 year period ( 78%) Robinson’s 5 year study 2004. • Pragmatic, collaborative approach needed (IEPA 2005) • Regular review/ Minimum effective dose • In full remission-gradual withdrawal after 12 months of remission. • If severe episode/slow response-withdrawal after 2 years • Incomplete recovery/frequent relapses-upto years/long term

25. Cost Impact of EI services • An ‘Invest to save’ argument for commissioners. Despite its higher running costs, EI service can potentially save in the order of £5000 in year one, rising to £14 000 by year three per case compared to treatment as usual (McCrone et al 2008) • Cost savings reflect mainly reductions in admission and readmission rates achieved by EI services by: • Early detection, education and collaboration with primary care an community agencies • Stronger engagement and more age/phase appropriate intervention with individual and families.

26. All too good to be true…? •  A 2012 systematic review of the evidence concluded stated that: "The published literature does not support the contention that early intervention for psychosis reduces costs or achieves cost-effectiveness“ (Amos 2012)

27. Eleanor’s story • A student who started hearing voices • Her story about her journey through to recovery • She went on to achieve a masters in Psychologist and has worked in EI services http://www.ted.com/talks/eleanor_longden_the_voices_in_my_head.html

28. Does this challenge your perception of prognosis for a psychotic illness?

29. 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/

31. CASC practise…. Linked station “An 18 year old student is referred for assessment by the GP. The patient is perplexed, frightened and expresses ideas of persecution. He is willing to be admitted to hospital. He has no previous psychiatric history.”

32. Station a: Your consultant catches you before you see the patient to admit him to the ward and wants to discuss the differential diagnosis and how you intend to proceed over the next 48 hours.

33. Station b: The patient’s mother turns up and asks what is going on, she saw a programme on bipolar disorder and wonders if this is what her son has? She wants to know what the management plan is and if he will be able to go back to university. She wants to know if she should take him home? She has heard about early-onset services and what the options are?