Early Intervention in PsychosisEarly Intervention in Psychosis

Alison Blair, Consultant PsychiatristAlison Blair, Consultant Psychiatrist

Janice Harper, Consultant Clinical PsychologistJanice Harper, Consultant Clinical Psychologist

Esteem GlasgowEsteem 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

ESTEEM Clinical ModelESTEEM Clinical Model Home based care Home based care

Formulation derived care plan Formulation derived care plan

Integrated Care Pathway Integrated Care Pathway

Holistic approachHolistic approach

Evidence based interventions with timely access to Evidence based interventions with timely access to psychological therapies ( 70 % caseload referred to psychological therapies ( 70 % caseload referred to Clinical Psychology)Clinical Psychology)

Co morbidity ( 66% substance/alcohol abuse, 35% Co morbidity ( 66% substance/alcohol abuse, 35% depression, 10% Autistic Spectrum Disorder)depression, 10% Autistic Spectrum Disorder)

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

DELIVERY TARGETS (from relevant ICP Condition-Specific Standards / ESTEEM Policies)

Psychoeducational, psychological, psycho-social therapies delivered within 3 months of referral, with subsequent reviews of individual’s progress

Evidence based medication algorithm is followed, including for medication resistant psychosis (e.g. SIGN; NICE guidelines)

If patient disengages, continue to engage with family as required OR transfer of care between services / discharge to GP. If discharged < 2 years, log reason for discharge

Correspondence updating GP at a minimum of every three months

Suspected psychosis:Assessment within 5 daysAllocate key-workerAssertive engagementCollateral historyAssessment discussed with MDTMDT assessment if requiredDepression Screening (BDI-II)If discharge: Inform referrer of assessment outcome / advise re. re-referral if problems persist

MDT Formulation within 12 weeks, inc. plan of interventions

Review of 1st care plan 3 months from formulation

1. Self Report Questionnaires (BDI-II, AUDIT, DAST, SAS) at 0-6 weeks and 12 weeks completed by service-user with staff member 2. Self Report Questionnaires at 6 months and 12 months completed by service user with Research Assistant unless agreed for staff member to administer.3. PANSS IS COMPLETED BY PSYCHIATRIST (with negotiation this can be passed on to other PANSS trained staff) 4. Service Engagement Scale and AUS/DAS are completed by key-worker in collaboration with MDT (e.g. at formulation session)5. ECGI is completed by ‘carer / main social or practical support figure in client’s life’ with RA or staff member

OUTCOME MEASURES & FORMS

Complete the following for all confirmed cases of First Episode Psychosis

Client & Carer Consent ProceduresPositive and Negative Syndrome Scale (PANSS)

Beck Depression Inventory (BDI-II)Alcohol-Use Disorders Identification Test (AUDIT)

Drug Abuse Screening Test (DAST)Alcohol & Drug Use Scales (AUS/DUS)ESTEEM Service Receipt Inventory (Entry Form – completed by 6 weeks)

PANSSBDI-IIAUDIT/DAST/AUS & DUSService Engagement Scale (SES) & Service Attachment Scale (SAS) Experience of Care Giving Inventory (ECGI)ESTEEM Service Receipt Inventory (3 month)Consider if at risk of arrested recovery if SES score > 12 and prioritise formulation / re-formulation

PANSSBDI-II

SESSAS

Process of Recovery Questionnaire (QPR)

ESTEEM Service Receipt Inventory (6 month)

Consider if at risk of arrested recovery if SES score > 12 and

prioritise re-formulation

PANSSBDI-II

SESSAS

AUDIT/DAST/AUS&DUSQPRECGI

ESTEEM Service Receipt Inventory (1 year)

Consider if at risk of arrested recovery if SES score > 12 and

prioritise re-formulation

PANSSBDI-II

SESSAS

AUDIT/DAST/AUS&DUSQPRECGI

ESTEEM Service Receipt Inventory (2 year)

Consent to long-term follow-upExit Interview

ICP REVIEWS: DOCUMENTS & ASSESSMENTS

Risk assessmentADMIN:

Personal Data SheetStandard letter

acknowledging referral sent to GP / referrer

ICP diary initiated from date of acceptance onto

ESTEEM caseloadPSYCIS

Physical Health CheckGASS

Initial assessment document to GP/referrer

with outcome (acceptance/discharge)

ICP Review MeetingICP Indicator Forms (OT / Psychology)AVONHONOSGASSGlasgow Risk ScaleCopy of ICP care plan to client/GP

ICP Review MeetingGlasgow Risk Scale

Copy of ICP care plan to client/GP

Schedule annual MDT case discussion

ICP Annual ReviewGlasgow Risk Scale

GASSPhysical Health Check

Copy of ICP care plan to client/GP

ICP Indicator Forms (OT/psychology)

Predischarge ICP reviewAVONHONOSGASSGlasgow Risk ScalePSYCISPhysical Health CheckTransfer of Care Document, inc. copy to GP

REFERRAL 0 - 6 WEEKS 3 MONTHS 6 MONTHS 1 YEAR 2 YEARESTEEM First Episode Psychosis Service NHS Greater Glasgow & Clyde - 2011

SIGN RecommendationsSIGN Recommendations There is consistent evidence that EI services have benefit There is consistent evidence that EI services have benefit

for engagement rates, readmission rates, access to family for engagement rates, readmission rates, access to family interventions and other psychological interventions and interventions and other psychological interventions and rates of functional recovery in patients with first episode rates of functional recovery in patients with first episode psychosis. psychosis.

Cost Effectiveness of Early InterventionCost Effectiveness of Early Intervention

““Early Intervention costs more in the first year of care Early Intervention costs more in the first year of care (compared to standard care) because of the higher rates (compared to standard care) because of the higher rates of contacts with multi professionals, thereafter per of contacts with multi professionals, thereafter per patient EI costs considerably less than standard care, patient EI costs considerably less than standard care, largely due to inpatient savings” ( Knapp et al., 2011)largely due to inpatient savings” ( Knapp et al., 2011)

“ “ If EI services extended to cover the total population of If EI services extended to cover the total population of England, estimated net savings to the NHS would England, estimated net savings to the NHS would amount to £290 million, increasing to £ 550 million if amount to £290 million, increasing to £ 550 million if wider economic savings were taken into account” wider economic savings were taken into account” Department of Health Department of Health

Glasgow Edinburgh First Episode Glasgow Edinburgh First Episode Psychosis Study 2006-2009Psychosis Study 2006-2009

Three centres in Glasgow (ESTEEM), Edinburgh Three centres in Glasgow (ESTEEM), Edinburgh (EPSS and Adult CMHT services)(EPSS and Adult CMHT services)

Study aimed to characterise a sample of participants, Study aimed to characterise a sample of participants, investigate the role of attachment in the evolution of investigate the role of attachment in the evolution of psychiatric symptomatology and service engagementpsychiatric symptomatology and service engagement

OUTCOMESOUTCOMES

DUP Edinburgh 23 weeks vs Glasgow 13DUP Edinburgh 23 weeks vs Glasgow 13

Days as in-patients Edinburgh 72 vs Glasgow 33 Days as in-patients Edinburgh 72 vs Glasgow 33 ( in first 12 months)( in first 12 months)

Glasgow patients had less positive symptoms Glasgow patients had less positive symptoms and lower scores on general psychopathologyand lower scores on general psychopathology

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

Bed days per 100,000 NRAC adjusted population for admissions 18-24 years old with a primary diagnosis of psychosis by NHS Board 2009/10

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

NHS GreaterGlasgow &

Clyde

NHSLanarkshire

NHSGrampian

NHS Lothian NHS Fife NHS ForthValley

NHSAyrshire &

Arran

NHSDumfries &Gallow ay

NHSBorders

NHS Tayside NHSHighland

NHS Board

Bed

days

per

100

,000

po

pula

tion

NHS Board 18-24's Scotland 18-24's

EI in Psychosis Service DeliveryEI in Psychosis Service Delivery

The Mental Health Policy Implementation GuideThe Mental Health Policy Implementation Guide (DOH 2001)(DOH 2001)

14 to 35 year age entry criteria 14 to 35 year age entry criteria First three years of psychotic illness First three years of psychotic illness Aim to reduce the duration of untreated psychosis to Aim to reduce the duration of untreated psychosis to

less than 3 months less than 3 months Maximum caseload ratio of 1 care coordinator to 10–Maximum caseload ratio of 1 care coordinator to 10–

15 clients 15 clients For every 250,000 (depending on population For every 250,000 (depending on population

characteristics), one team characteristics), one team • Total caseload 120 to 150 Total caseload 120 to 150 • 1.5 doctors per team 1.5 doctors per team • Other specialist staff to provide specific evidence based Other specialist staff to provide specific evidence based

interventions interventions

NEIP Core service features (2005)NEIP Core service features (2005)

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

Models of implementation in UKModels of implementation in UK

Specialist Team ModelSpecialist Team Model The service is provided through a stand-alone specialist The service is provided through a stand-alone specialist

team. team. All staff work predominantly for the team and have a shared All staff work predominantly for the team and have a shared

task to provide EIP services. task to provide EIP services. This is the model based on evidence from early EI and This is the model based on evidence from early EI and

Assertive Outreach services.Assertive Outreach services.

Dispersed or CMHT ModelDispersed or CMHT Model

The service is provided by staff (full or part-time) The service is provided by staff (full or part-time) embedded within an existing service, usually a Community embedded within an existing service, usually a Community Mental Health Team (CMHT). Staff are expected to follow Mental Health Team (CMHT). Staff are expected to follow core principles of care, but often have limited contact with core principles of care, but often have limited contact with people in similar roles. Limited evidence (See Fowler people in similar roles. Limited evidence (See Fowler et al. et al. 20092009) )

Hub and Spoke ModelHub and Spoke Model

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

Benefits and deficits of EIP service modelsBenefits and deficits of EIP service models (Dodgson & McGowan, 2010)(Dodgson & McGowan, 2010)

Specialist DispersedSpecialist Dispersed H & SH & S

Evidence Base to support Evidence Base to support XX XX

Promotes team approach Promotes team approach X X X X Promotes clear EIP value Promotes clear EIP value base/philosophy base/philosophy X X ??Consistency of practice Consistency of practice X X Promotes recruitment and Promotes recruitment and retention retention ? ? ??Promotes development of Promotes development of specialist skills specialist skills X X ??Strong local presence X Strong local presence X Value for money Value for money ? ? ??May benefit other May benefit other community teams community teams ? ? Easy to ring-fence EIP Easy to ring-fence EIP resource resource XX ? ?

Outcomes from service modelsOutcomes from service models Fowler et al (2009) compared comprehensive EI service Fowler et al (2009) compared comprehensive EI service

with CMHT service with specialist EI workers attached to with CMHT service with specialist EI workers attached to CMHT:CMHT:

Generic CMHT, only 15% individuals made full or partial Generic CMHT, only 15% individuals made full or partial recovery at 2 years.recovery at 2 years.

Specialist EIP workers in collaboration with traditional Specialist EIP workers in collaboration with traditional CMHT care, 24% made a partial or full recovery.CMHT care, 24% made a partial or full recovery.

Comprehensive EI service, 52 % made full or partial Comprehensive EI service, 52 % made full or partial recovery at 2 years and significant reductions in recovery at 2 years and significant reductions in admissions was an added benefit.admissions was an added benefit.

Delivering EIPDelivering EIP

Each model has strengths and weaknessesEach model has strengths and weaknesses Specialist team best outcomesSpecialist team best outcomes Challenge is to establish the model that is most Challenge is to establish the model that is most

pertinent to the needs of the locality but also pertinent to the needs of the locality but also meets the core service features and clinical meets the core service features and clinical interventions that evidence shows are required interventions that evidence shows are required for successful EI.for successful EI.

EIP has to be value for money therefore EIP has to be value for money therefore promised outcomes must be achievedpromised outcomes must be achieved

Risks in alternative service models are that Risks in alternative service models are that outcomes are not achievedoutcomes are not achieved

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

SIGN RecommendationsSIGN Recommendations

EIP Service DeliveryEIP Service Delivery

Best practice principlesBest practice principles Evidence base and Early Psychosis Evidence base and Early Psychosis

DeclarationDeclaration ButBut Demography, geography, resources, Demography, geography, resources,

financial pressures mean compromise.financial pressures mean compromise. What principles of EI are non negotiable?What principles of EI are non negotiable? Practical and effectivePractical and effective

Minimum Fidelity Standards for New EIP ServicesMinimum Fidelity Standards for New EIP Services (NIMHE 2005)(NIMHE 2005)

Involvement of all stakeholders including CAMHS in service Involvement of all stakeholders including CAMHS in service planningplanning

Optimally a discrete Optimally a discrete specialist team or hub & spokespecialist team or hub & spoke that that meets minimum standards for team definitionmeets minimum standards for team definition

A coherent group of specialist practitioners whose sole/main A coherent group of specialist practitioners whose sole/main responsibility is EIP with common aims and objectives, responsibility is EIP with common aims and objectives, philosophy of care and agreed care standardsphilosophy of care and agreed care standards

Explicit leadership that provides specialist supervision, work Explicit leadership that provides specialist supervision, work allocation,fidelity monitoring, service & staff development and allocation,fidelity monitoring, service & staff development and performance managementperformance management

Assertive outreach to those who require itAssertive outreach to those who require it Clarified medical responsibility for patients Clarified medical responsibility for patients Interventions: as per policy implementation guideInterventions: as per policy implementation guide Capacity: sufficient capacity to meet the actual level of local Capacity: sufficient capacity to meet the actual level of local

need Capacity to be based on care-coordinator caseloads of need Capacity to be based on care-coordinator caseloads of 10-15 and an intention to see clients for 3 years10-15 and an intention to see clients for 3 years

Audit and Information: local information gathered to enable Audit and Information: local information gathered to enable audit including evaluations of outcomesaudit including evaluations of outcomes

Essential clinical components of EIEssential clinical components of EI Staff trained in EI approach and interventionsStaff trained in EI approach and interventions ICP to guide and ensure fidelityICP to guide and ensure fidelity True MDT work incorporating all disciplines including True MDT work incorporating all disciplines including

dedicated Consultant Psychiatrist and Psychologist dedicated Consultant Psychiatrist and Psychologist Comprehensive MDT assessmentComprehensive MDT assessment

Developmental history from family membersDevelopmental history from family members Assessment of family functioningAssessment of family functioning

Formulation driven care planFormulation driven care plan Highlights potential barriers and risks and directs specific Highlights potential barriers and risks and directs specific

interventionsinterventions Ongoing family work including formal therapy where Ongoing family work including formal therapy where

indicatedindicated Intensive support and outreach to engageIntensive support and outreach to engage Crisis functionCrisis function

DiscussionDiscussion

Delivering EI in Rural locations: which model?

What is your expected caseload of 1st Episode Psychosis?

(For every 250,000 (depending on population For every 250,000 (depending on population characteristics), one team ; Total caseload 120 to 150)characteristics), one team ; Total caseload 120 to 150)

Is EI currently being delivered?

What are the current resources?

What skills training would be required?