Earlier intervention in psychosis - everybody’s business
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Transcript of Earlier intervention in psychosis - everybody’s business
Earlier intervention in psychosis - everybody’s business
A primary care view
Dr David ShiersDr Jo Smith
Joint leads NIMHENational 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
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)
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
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
Context: – Knowledge of individual before onset of
psychosis
– Family practice
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
Victoria (Aus) Burden of Disease Study: Incident Years Lived with
Disability rates per 1000 population by mental disorder
GPs see a FEP at an age when other serious mental disorders tend to develop
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 full-
time education
Pathway players (n = 45)
General psychiatrists 45 Health visitor 3Family members 37 Work colleagues 3
GP 36 Private landlord 2
Police 22 Church 2
CPN 18 Occupational health 2
A&E 13 Friends 2
SW 11 O T 2
Psychologist 5 General physician 1
Teacher / Tutor 4 Learning diff psychiat 1
Neighbour 4 Forensic psychiatrist 1
Police surgeon 4 Substance misuse 1
Hostel staff 4 Homeless services 1
Probation officer 3 Solicitor 1
Prison staff 3 Ambulance services 1
Resource centre 3 Public Health 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!!!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…
Stagnation in a ghetto of disability
Relapse and remission
Path to social exclusion and health inequality?
“…“…can’t get a job, can’t get a can’t get a job, can’t get a girlfriend, can’t get a telly, can’t girlfriend, can’t get a telly, can’t get nothing… it’s just everything get nothing… it’s just everything falls down into a big pit and you falls down into a big pit and you can’t get out…” can’t get out…” Hirschfeld, 2002Hirschfeld, 2002
“…“…our overwhelming feeling was of an our overwhelming feeling was of an opportunity missed - to what degree she opportunity missed - to what degree she has been needlessly disabled by those has been needlessly disabled by those first four years of care we’ll never know” first four years of care we’ll never know” Mother 2002Mother 2002
... a path to inequality Excluded
12% with a job In previous 2 weeks (Nithsdale survey)
o 39% either had no friends or had met noneo 34% had not gone out sociallyo 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 disordersEg. 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?What do young people and families need?
OptimismOptimism
Confidence in a whole systems response to their help-Confidence in a whole systems response to their help-seekingseeking
Earlier detectionEarlier detection– of psychosisof psychosis– of ‘at risk mental state’?of ‘at risk mental state’?
Specialist services that Specialist services that – ‘‘do psychosisdo psychosis’ as well as ’ as well as ‘do young people’‘do young people’– pre-empt crisis; offer less traumatic ‘first engagements’ pre-empt crisis; offer less traumatic ‘first engagements’ – offer age / phase specific care in ‘critical period’ of first 3-5 yrsoffer age / phase specific care in ‘critical period’ of first 3-5 yrs– provide recovery oriented services from the startprovide recovery oriented services from the start
Support for familiesSupport for families
What do specialist services need What do specialist services need from primary care?from primary care?
GPs as key pathway players to:GPs as key pathway players to:– Listen for and act on family concernsListen for and act on family concerns– Be aware of key indicatorsBe aware of key indicators– Be flexible and accessible to promote help-Be flexible and accessible to promote help-
seeking of these young peopleseeking of these young people– Involve EIS at the earliest opportunityInvolve EIS at the earliest opportunity– Organise care to meet physical health needOrganise care to meet physical health need
What does primary care need from What does primary care need from specialist services?specialist services?
Youth friendly approach – ban outpatient clinics!Youth friendly approach – ban outpatient clinics!
Low threshold of access to specialist adviceLow threshold of access to specialist advice– MH assessment of those with suspected FEPMH assessment of those with suspected FEP– Monitoring / review of those deemed at ‘high risk’ of FEPMonitoring / review of those deemed at ‘high risk’ of FEP– Individual support for FEP Individual support for FEP
Collaborative approach Collaborative approach – Clear pathways (e.g. for those aged 14-18; for those with Clear pathways (e.g. for those aged 14-18; for those with
co-morbid drug misuse) co-morbid drug misuse) – Relapse planning Relapse planning – Planned exit from EIS Planned exit from EIS
Marketing EI to primary care?
Colin’s journey
RapidsRapids
EddyEddy
FamilyFamily
PCPC
Family crisis
Drop out of Educ’n
Isolated from friends
Suicide attempt
Offending behaviour
Mental illness
Homeless
Drugs
RapidsRapids
RapidsRapids
No money
Distressed
No job
Youth Youth workerworker
Using Nature – EddiesEarly 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
Safety raft
White water
Rapids
Eddy
Family
Guides
Lookout with life ring
Supporting GPs’ to do a difficult
job better:
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
Early intervention is everybody’s business
EI services insufficient by themselves
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
Equipped for the life Equipped for the life ahead both for the ahead both for the
young person and their young person and their familyfamily
www.earlydetection.csip.org.uk
Thank you