Early Intervention in Psychosis

1. Early Intervention in Psychosis Alison Blair, Consultant Psychiatrist Janice Harper, Consultant Clinical Psychologist

2. Esteem Glasgow • Patient group 16-35 yrs with first episode psychosis • Assessment and treatment • In- patient and out-patient care, crisis and assertive outreach • Working with families • Maximising recovery • Minimising trauma

3. ESTEEM Clinical Model • Home based care • Formulation derived care plan • Integrated Care Pathway • Holistic approach • Evidence based interventions with timely access to psychological therapies ( 70 % caseload referred to Clinical Psychology) • Co morbidity ( 66% substance/alcohol abuse, 35% depression, 10% Autistic Spectrum Disorder)

4. Currently 3 teams across Greater Glasgow • Clinical Co-ordinators • Community Psychiatric Nurses • Occupational therapists • Support workers • Consultant and other grades of Psychiatrist • Consultant and other grades of Clinical Psychologist

5. ESTEEM First Episode Psychosis Service NHS Greater Glasgow & Clyde - 2011

6. SIGN Recommendations There is consistent evidence that EI services have benefit for engagement rates, readmission rates, access to family interventions and other psychological interventions and rates of functional recovery in patients with first episode psychosis.

7. Cost Effectiveness of Early Intervention “Early Intervention costs more in the first year of care (compared to standard care) because of the higher rates of contacts with multi professionals, thereafter per patient EI costs considerably less than standard care, largely due to inpatient savings” ( Knapp et al., 2011) “ If EI services extended to cover the total population of England, estimated net savings to the NHS would amount to £290 million, increasing to £ 550 million if wider economic savings were taken into account” Department of Health

8. Glasgow Edinburgh First Episode Psychosis Study 2006-2009 • Three centres in Glasgow (ESTEEM), Edinburgh (EPSS and Adult CMHT services) • Study aimed to characterise a sample of participants, investigate the role of attachment in the evolution of psychiatric symptomatology and service engagement

9. OUTCOMES • DUP Edinburgh 23 weeks vs Glasgow 13 • Days as in-patients Edinburgh 72 vs Glasgow 33 ( in first 12 months) • Glasgow patients had less positive symptoms and lower scores on general psychopathology

10. Figure 2.4b: Five-fold variation in bed days for admissions with a primary diagnosis of psychosis for individuals aged 18-24 years

11. EI in Psychosis Service Delivery

12. The Mental Health Policy Implementation Guide (DOH 2001) • 14 to 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

13. NEIP Core service features (2005) • Stand-alone service model • Dedicated consultant psychiatrist input • Full age range (14^35 years) • Care provided for up to 3 years • Assertive community outreach work • Extended opening hours • Case-loads of 10^15 • Adolescent provision • Primary care referral • Designated access to acute beds

14. Models of implementation in UK • Specialist Team Model • The service is provided through a stand-alone specialist team. • All staff work predominantly for the team and have a shared task to provide EIP services. • This is the model based on evidence from early EI and Assertive Outreach services.

15. Dispersed or CMHT Model • The service is provided by staff (full or part-time) embedded within an existing service, usually a Community Mental Health Team (CMHT). Staff are expected to follow core principles of care, but often have limited contact with people in similar roles. Limited evidence (See Fowler et al. 2009)

16. Hub and Spoke Model • This model is a cross between the above two models. The service is provided by staff who are be embedded in ‘spokes’, often CMHTs, and in the central ‘hub’. The hub usually provides access to leadership, specialist skills and support to the spoke workers. This model is often found in rural areas.

17. Benefits and deficits of EIP service models (Dodgson & McGowan, 2010) Specialist Dispersed H & S Evidence Base to support  X X Promotes team approach  X X Promotes clear EIP value base/philosophy  X ? Consistency of practice  X  Promotes recruitment and retention  ? ? Promotes development of specialist skills  X ? Strong local presence X  Value for money  ? ? May benefit other community teams ?  Easy to ring-fence EIP resource  X ?

18. Outcomes from service models Fowler et al (2009) compared comprehensive EI service with CMHT service with specialist EI workers attached to CMHT: Generic CMHT, only 15% individuals made full or partial recovery at 2 years. Specialist EIP workers in collaboration with traditional CMHT care, 24% made a partial or full recovery. Comprehensive EI service, 52 % made full or partial recovery at 2 years and significant reductions in admissions was an added benefit.

19. Delivering EIP • Each model has strengths and weaknesses • Specialist team best outcomes • Challenge is to establish the model that is most pertinent to the needs of the locality but also meets the core service features and clinical interventions that evidence shows are required for successful EI. • EIP has to be value for money therefore promised outcomes must be achieved • Risks in alternative service models are that outcomes are not achieved

20. A key challenge for us all is delivery of EIP, not just in urban inner city areas but also in rural settings

21. SIGN Recommendations

22. EIP Service Delivery • Best practice principles • Evidence base and Early Psychosis Declaration • But • Demography, geography, resources, financial pressures mean compromise. • What principles of EI are non negotiable? • Practical and effective

23. Minimum Fidelity Standards for New EIP Services(NIMHE 2005) • Involvement of all stakeholders including CAMHS in service planning • Optimally a discrete specialist team or hub & spoke that meets minimum standards for team definition • A coherent group of specialist practitioners whose sole/main responsibility is EIP with common aims and objectives, philosophy of care and agreed care standards • Explicit leadership that provides specialist supervision, work allocation,fidelity monitoring, service & staff development and performance management • Assertive outreach to those who require it • Clarified medical responsibility for patients • Interventions: as per policy implementation guide • Capacity: sufficient capacity to meet the actual level of local need Capacity to be based on care-coordinator caseloads of 10-15 and an intention to see clients for 3 years • Audit and Information: local information gathered to enable audit including evaluations of outcomes

24. Essential clinical components of EI • Staff trained in EI approach and interventions • ICP to guide and ensure fidelity • True MDT work incorporating all disciplines including dedicated Consultant Psychiatrist and Psychologist • Comprehensive MDT assessment • Developmental history from family members • Assessment of family functioning • Formulation driven care plan • Highlights potential barriers and risks and directs specific interventions • Ongoing family work including formal therapy where indicated • Intensive support and outreach to engage • Crisis function

25. Discussion • Delivering EI in Rural locations: which model? • What is your expected caseload of 1st Episode Psychosis? • (For every 250,000 (depending on population • characteristics), one team ; Total caseload 120 to 150) • Is EI currently being delivered? • What are the current resources? • What skills training would be required?