Early Intervention in Psychosis History, Model and Progress

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Early Intervention in Psychosis - History, Model
and Progress
S.McGowan Bradford Airedale EIP Lead Associate
for EIP, NIMHE/CSIP
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Part 1

• The Early Intervention Years1986-2006

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1986

• Closure of the Asylums
• Rehabilitation, behaviour modification and
  novel antipsychotics
• Charitable e.g. NSF
• Johnstone et al Treatment delay and outcome
• EPPIC conceived in Australia

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1987-1996

• 1987 Birchwood et al Critical Period
  hypothesis
• 1990 Care in the Community
• 1991 Thorn/PSI
• 1993 Romme Escher Accepting Voices
• 1995 North Birmingham service launched
• 1995 Fowler et al CBT for Psychosis

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1997-99

• PRIME, RAPP, TIPPS, OPUS, FETZ, Toronto, Calgary
  and Nova Scotia
• Coleman Smith Victim to Victor (1997)
• 1998 IEPA launched
• 1998 Modernising MH services
• 1999 MH National Service Framework
• A small handful of EIP teams in the UK

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2000

• IRIS toolkit
• A handful of EIP teams in the UK
• NHS (national) plan 50 EIP teams by 2004

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2001

• A slack handful of EIP teams in the UK
• Norman and Malla Delay and outcomes
• Harrison et al Predictive value of early
  outcomes
• PIG

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2002

• NICE schizophrenia guideline
• CBT, ACT, low dose atypicals, family
  interventions
• McGorry, Yung et al Reducing risk of progression
  to first episode psychosis
• Rethink Reaching People Early
• Newcastle Declaration

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2003

• Childrens NSF
• Fidelity and Flexibility
• Windows of Opportunity (SCMH)
• EIP projects establishing across all parts of
  England
• Pelosi (2003)

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2004

• EIP target reframed
• NIMHE/Rethink mapping exercise
• 8/81 well established teams
• NIMHE/Rethink National EI Programme
• Early Psychosis Declaration

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2005

• FERN, EPOS, National EDEN, AESOP, LEO and the
  London Network, PSYGRID
• 40 teams (DH)
• NSF 5 years on

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2006

• Recovery Plan
• Cochrane Database
• French Morrison ARMS
• Cost Economic Analysis (DH/IOP)
• 60/120 teams in UK
• 3/14 in Yorkshire and Humber on target
• Social movement?

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Part 2

• First Episode Psychosis

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First Episode Psychosis

• What is psychosis?
• Incidence and occurrence
• Clinical profile of first episode psychosis
• 5 phases model
• Theories on the cause of psychosis

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What is Psychosis?

• Psychosis or schizophrenia?
• Thought disorder.
• Traditionally associated with frequent relapse,
  chronic disability and poor social outcomes.
• Very high risk of suicide.
• Positive and negative symptoms

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Positive and negative symptoms of psychosis

• Hallucinatory voices.
• Thought echo, insertion, withdrawal, broadcast.
• Delusions
• Paranoia
• Delusions of passivity.

• Loss of motivation
• Flattened emotions
• Lethargy
• Anhedonia
• Social withdrawal

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Incidence and occurrence

• Schizophrenia 1100
• FEP 15 per 100,000
• Age range
• Gender differences
• BME communities
• Link with poverty

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Profile of a typical first episode psychosis
client

• Young
• Black
• Poor and/or disadvantaged
• Treatment naïve
• Incomplete social, emotional and educational
  development.
• Substance misuser

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The five phases model
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DUP
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Theories on the cause of psychosis

• Biological
• Psychological
• Social
• Spiritual
• Individual

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Stress-vulnerability Model(Zubin and Spring,
1977)

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Part 3

• Early Intervention

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Early Intervention

• The Concept of Early Intervention
• The Critical Period
• The Early Intervention paradigm
• Core features of the EIP approach
• Service configuration for EIP
• Drivers for EIP
• Where are we now

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Classic view of psychosis
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Progressive view of psychosis

• The experience of psychosis is understandable
• Psychosis is on a continuum with other human
  experiences
• Problems resulting from stigma, social exclusion
  and poverty are of equal importance
• Psychosis can be an enriching, as well as a
  frightening/confusing experience.
• The person is an expert in their own care
• A collaborative approach is required
• The person will make a good recovery

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The EIP concept

• Early intervention in psychosis amounts to
  deciding if a psychotic disorder has commenced
  and then offering effective treatment at the
  earliest possible point and secondly ensuring
  that intervention constitutes best practice for
  this phase of illness, and is not just the
  translation of standard treatments developed for
  later stages and more persistently ill subgroups
  of the disorder.
• (McGorry et al 1996).

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Characteristics of EIP services

• They accept that a persons diagnosis may be
  uncertain
• They focus simultaneously on young people and
  their families
• They offer treatment in the least restrictive and
  stigmatising setting
• They emphasise the importance of access,
  flexibility and choice to increased service uptake

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Characteristics of EIP services

• They seek to make peoples lives as normal as
  possible while in contact with services
• They aim to reduce the likelihood of trauma,
  depression and suicide
• They place an emphasis on the wider social roles
  that service users play to maximise their social,
  educational and work opportunities
• They aim to maximise an individuals potential for
  recovery during the critical period

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Evidence

• Research Findings
• Delayed treatment has serious consequences
• Early intervention can reduce long term morbidity

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Evidence

• International research
• Patrick McGorry (Aus)
• Tom McGlashan (USA)
• Jan Johannessen (Norway)
• Max Birchwood (UK)
• Tony Morrison and Paul French (UK)

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Status of existing evidence

• Evidence for EIP PIG?
• Evidence for TAU?
• Evidence for EIP components?

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The Critical Period Hypothesis.

• Psychosis may be neurologically toxic.
• Disability develops aggressively in the first 3
  years.
• Early Intervention can reduce 3 yr relapse rates
  from 80 to lt20.
• Social/personal functioning stabilises after 3-5
  years.
• High suicide risk in critical period.

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Early Intervention Paradigm.
Early Detection
Reduced Treatment Delays
Sustained Intervention Through The Critical
Period
Improved Outcomes
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Key features of an Early Intervention Approach

• Early detection, assessment and acceptance of
  diagnostic uncertainty
• A full range of psychosocial interventions
  including CBT for psychosis
• Relapse prevention
• Best practice prescribing
• A focus on young people and their cultural and
  developmental needs

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Key features of an Early Intervention Approach

• Assertive engagement
• Support for families
• Attention to co-morbidities such as substance
  misuse, anxiety, depression, and PTSD
• Housing, income and practical support
• Proper attention to education, employment,
  occupational and developmental needs
• Age (etc.) appropriate acute care

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Service fidelity

• MDT and leadership
• Accessibility
• ACT
• Age range
• Caseloads, duration and capacity
• Needs audit
• DUP and Outcomes

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Service configuration for EIP

• PIG model
• Hub and spoke
• Dispersed/CMHT model
• TIPS model
• Issues concerning rural localities and small
  services

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Drivers for Early Intervention

• Research evidence
• Innovators
• Recovery movement
• User/carer perspective
• New treatments
• Challenges to dominance of biological model
• IEPA, IRIS, WHO, SCMH, NIMHE
• DH

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Where are we now?

• Partial implementation of EIP
• Reorganised NHS Procurement, provision and
  contestability
• NSF 5, Louis Appleby, December 2004
• Shift focus from specialist teams to the MH needs
  of the whole community.
• Access and Choice.
• The care of long-term conditions.

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The NSF 5, Key Areas for further Action

• In-patient care and environment
• Services for people with dual diagnosis
• Social Inclusion
• Opposing stigma and discrimination
• Better services for BME communities
• Better care of long-term MH disorders in primary
  care
• Increased availability of psychological therapies

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Where next for EIP?

• Service models and effectiveness
• Comprehensive services
• - Primary prevention
• - Early detection
• - Acute care
• - Social recovery
• EPD standards
• Meaningful outcomes