Early intervention in psychosis UK, a fascinating odyssey

1
Early intervention in psychosis UK, a fascinating
odyssey
2
The UK early intervention service reforms

• A grassroots and consumer led service reform
• Government policy and funding
• Theres gt120 teams in the country
• Based on robust scientific rationale
• EI works and pays for itself in a year

3
EI case load from LDPR ( yr-end figures)
1 team 24 teams 41teams
109 teams 118 teams ?teams
4
(No Transcript)
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7

8
Service reformA national declaration

• Long DUP (12 months)
• Engagement by compulsion (gt50)
• High service disengagement
• (50 in 18 months) services stigmatising
• and alienate youth
• Services not focus on social inclusion
• 14-18yr group Continuity,
• admission to adult wards

9
National Plan for the NHS
Fifty early intervention services will be
established over the next three years to provide
treatment and active support in the community to
these young people and their families by 2004
all young people who experience a first episode
of psychosis will receive the early and intensive
support they need

DoH,2000

10
The Policy Implementation Guide
The PIG
11
(No Transcript)
12
Loss of contact with services is
concerningyoung people with psychosis require an
assertive, co-ordinated approach, p.40
80 of first inpatient admissions were to adult
facilitiessubstantial underprovision of age
appropriate facilities p.1
Untreated illness placed a large burden on
carers improving GP direct access to specialist
CAMHS would facilitate better management p.41
Closer working between CAMHS and adult services
would reduce ..unmet need p.1
13
(No Transcript)
14
The National EDEN sites
Lancashire Wirral 5 teams (Marshall/Lewis/Sharma
)
Birmingham 4 teams (Birchwood/Lester)
East Anglia 2 teams (Jones/Fowler)
Cornwall 1-2 team (Amos/Harrison)
15
Publicity capitalise on disaster cases
Form pressure group of concerned consumers
Link with politically sensitive areas (BME)
Stage 1 EI is overdue service reform
Alliance with National Mental health campaigning
NGO big names
Consumer led conferences invite ministers
Ministerial /political alliance
16
EIS IRIS guidelines endorsed by WHO
Engage leading academics
Unacceptable Services FEP and suicicde
Scientific respectability
National scientific conferences
Political Engagement consumers and opinion
leaders
Focus on overwhelming evidence base
17
National EI 3 yr development project training
and fidelity.NHS/NGO
Portfolio of meta-analyses, trials and rationale
for critical period .NICE guidelines.
EI service Fidelity
Stitched into the fabric of MH care
Ongoing RD On EI effectiveness take higher
moral ground on demonstrable outcomes/targets
Health economic analysis
Media success stories kudos to politicians
18
The evidence base is better than eg. Forensic
psychiatry. Evidence base for status quo?
Leading academics invested
EIS future, modern detractors self interest,
stuck in past
Strategy to deal with professional resistance
and jealousy
Loud Consumer Advocates would this be acceptable
in cancer? etc
Highlight Innovative practices NGO partnerships
All medicine has evolved into subspecialties
surgury
19
(No Transcript)
20
The future of EIS stand still and your dead

• Work and inclusion as core aim
• EIS commissioned with NHS NGOs
• EIS embedded in Youth Health and adolescence
• NHS no longer lead agency?

21
Birmingham Youth Health
Focus on Regeneration
Focus on communities
Focus On Training
Child and adolescent mental health services
22
(No Transcript)
23
(No Transcript)
24
The Danish OPUS Trial A randomized controlled
trial of integrated psychiatrictreatment for
first episode psychotic patients
British Medical Journal, Sept 16 2005
Merete Nordentoft, Bispebjerg Hospital,
Department of Psychiatry, 2004
25
(No Transcript)
26
National Plan for the NHS
Fifty early intervention services will be
established over the next three years to provide
treatment and active support in the community to
these young people and their families by 2004
all young people who experience a first episode
of psychosis will receive the early and intensive
support they need

DoH,2000

27
The Policy Implementation Guide
The PIG
28
EI case load from LDPR ( yr-end figures)
1 team 24 teams 41teams
109 teams 118 teams ?teams
29
The evidence base for early intervention?

• Growing understanding of interaction of
  psychosocial risk factors and continuum of
  vulnerability
• Majority of FEP have prodromal decline.
• DUP is 12months robustly linked to early
  outcome.
• Disability plateaus by 3 years
• Outcome at 3 years predicts outcome at 15.
• Suicide risk highest lt5yrs of onset.

30
Re-writing the textbooks New epidemiology of
psychosis

• Urbanicity
• Material deprivation
• Social fragmentation
• Social integration vs marginalisation

31
(No Transcript)
32
Why is psychosis X4 more frequent in the
inner-city?
Rate of first episode psychosis
Social fragmentation
33
(No Transcript)
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
Who are the services for?

• Age 14-35
• First psychotic episode
• Psychosis spectrum

40
What are the aims?

• Reduce DUP to min median of 12 weeks.
• Service engagement gt 90
• Sustained treatment for 3 years assure pathway
  to employment.
• Reduce suicide

41
What are their principles?

• Engagement in low stigma channels streaming of
  youth services
• No outpatients or day care
• Sustained engagement during critical period
  (3yrs)
• Focus on youth and social roles
• Seamless service across CAMHS/adult

42
The early intervention team

• Based on assertive outreach model
• 115 case ratio 120 max per team
• For 1M population 4 teams

43
Work andtraining
Low dose/ atypical medication
Substance misuse
Interventions
Monitoring for depression and suicidal thinking
Relapse prevention
Personal and Family adjustment
44
The Birmingham Early Intervention Service

• Initiated1989
• Adopted Outreach model1995

Sustained intervention over 3 years emphasising
social inclusion, social networks and individual
and family adaptation to psychosis
45
The EIS partnership
Focus on Regeneration
Focus on communities
Focus On Training
Child and adolescent mental health services
46
Birmingham

• Population 1,200,000
• Mean Jarman Index 18
• Multi-ethnic
• Incidence 50 per 100,000 / year in inner city

47
Wheres Birmingham?
48
(No Transcript)
49
Birmingham Early Intervention
4 EIS Outreach Teams
Early detection team EDIT
3 youth respite Units
Youth treatment program
EPOS Big EDDIE
REDIRECT
50
Assertive Outreach

• Mobile intensive intervention team model
• Service accessible,7 days a week, 365 days
• Case managernurse,S/W supported by assistant
  case managers from non-stat partner
• Flexibility and availability
• 115 staff-client ratio

51
(No Transcript)
52
(No Transcript)
53
(No Transcript)
54
Maintaining Engagement

• Accessible
• Low stigma settings
• Provide what young people want

55
Low stigma channels
56
What young people value and want..
57
(No Transcript)
58
Community Respite Units
5 place homes in community setting
Jointly managed with black housing agency
Keyworker uses respite as resource to manage
crisis
59
(No Transcript)
60

• Reducing DUP
• Working with at risk youth
• Community partnerships
• Anti-stigma campaigning

61
Preventing or delaying transition to psychosis
62
Prevention or delay of psychosisMcGorry et al
2002 Archives of General Psychiatry
making transition to psychosis
Months
63
EDIE A single blind randomised controlled trial
Cognitive Therapy vs. Treatment As
Usual Preliminary Results from 12 months Follow-up
Transition rate in per group
Transition criteria
64
Effectiveness
65
(No Transcript)
66
LEO Trial
All contacts with psychotic symptoms
screened (n319)

• Excluded (n175)
• gt 2 episodes
• Not Sz. Spectrum
• Out of area
• Known elsewhere
• Too old / young
• Lost

(n144)
Met criteria
Control (n73)
LEO (n71)
67
Contact at 18 months
In contact Leo vs Other X211.449 df 3 p lt.02
68
LEO ResultsRelapse at 18 Months
plt0.05
69
LEO ResultsPositive Negative Symptoms at 18
Months PANSS (N99)
plt0.05 plt0.01
70
LEO ResultsSocial Functioning at 18 Months GAF
(N98)
plt0.01
71
The Danish OPUS Trial A randomized controlled
trial of integrated psychiatric treatment for
first episode psychotic patients
British Medical Journal, Sept 16 2005
Merete Nordentoft, Bispebjerg Hospital,
Department of Psychiatry, 2004
72
(No Transcript)
73
Hospital admission and use of bed days during the
first year
  Integrated Standard Sig.
(N274) (N265)   Bed days first y, mean
61 82 lt0.05 Bed days second y, mean 27 35
0.12
Merete Nordentoft, Bispebjerg Hospital,
Department of Psychiatry, 2004
74
Proportion of patients with marked or severe
symptoms after one and two year
75
(No Transcript)
76
Base-Case Results (McCrone, Dhanasari, Knapp 2006)
77
Comparison of LEO vs. Estimate of Standard
Services Costs in First Episode Psychosis(2003
figures)
Annual NHS Costs
Based on ratios from Agustench Cabases
(2000) and from estimates by Guest Cookson
(1999) adjusting for 3 inflation
Total standard NHS cost (estimate) Total
26,851 over first 2 years
NHS Cost per patient per year
LEO costs per patient Total of 15,985 over
first 2 years
OASIS costs per patient Total of 3,375 over 6
months Saving of 38 (control costs 5,485)
Savings/patients in LEO in 2 years 10,866
(40.5 less than standard NHS costs)
(Power et al, 2004)
78
EDEN
The National EDEN project
DUP, service configuration and outcome

(Evaluating the Development and Impact of Early
iNtervention services in the West Midlands)
First-Episode
PSYGRID
E-science Grid
79
The National EDEN sites
Lancashire Wirral 5 teams (Marshall/Lewis/Sharma
)
Birmingham 4 teams (Birchwood/Lester)
East Anglia 2 teams (Jones/Fowler)
Cornwall 1-2 team (Amos/Harrison)
80
(No Transcript)
81
(No Transcript)
82
The future of EIS ?

• Work and inclusion as core aim
• EIS commissioned with NHS NGOs
• EIS embedded in Youth Health and adolescence
• NHS no longer lead agency?

83
(No Transcript)
84
Birmingham Youth Health
Focus on Regeneration
Focus on communities
Focus On Training
Child and adolescent mental health services
85
The Danish OPUS Trial A randomized controlled
trial of integrated psychiatrictreatment for
first episode psychotic patients
British Medical Journal, Sept 16 2005
Merete Nordentoft, Bispebjerg Hospital,
Department of Psychiatry, 2004
86
(No Transcript)
87
National Plan for the NHS
Fifty early intervention services will be
established over the next three years to provide
treatment and active support in the community to
these young people and their families by 2004
all young people who experience a first episode
of psychosis will receive the early and intensive
support they need

DoH,2000

88
The Policy Implementation Guide
The PIG
89
EI case load from LDPR ( yr-end figures)
1 team 24 teams 41teams
109 teams 118 teams ?teams
90
The evidence base for early intervention?

• Growing understanding of interaction of
  psychosocial risk factors and continuum of
  vulnerability
• Majority of FEP have prodromal decline.
• DUP is 12months robustly linked to early
  outcome.
• Disability plateaus by 3 years
• Outcome at 3 years predicts outcome at 15.
• Suicide risk highest lt5yrs of onset.

91
Re-writing the textbooks New epidemiology of
psychosis

• Urbanicity
• Material deprivation
• Social fragmentation
• Social integration vs marginalisation

92
(No Transcript)
93
Why is psychosis X4 more frequent in the
inner-city?
Rate of first episode psychosis
Social fragmentation
94
(No Transcript)
95
(No Transcript)
96
(No Transcript)
97
(No Transcript)
98
(No Transcript)
99
(No Transcript)
100
Who are the services for?

• Age 14-35
• First psychotic episode
• Psychosis spectrum

101
What are the aims?

• Reduce DUP to min median of 12 weeks.
• Service engagement gt 90
• Sustained treatment for 3 years assure pathway
  to employment.
• Reduce suicide

102
What are their principles?

• Engagement in low stigma channels streaming of
  youth services
• No outpatients or day care
• Sustained engagement during critical period
  (3yrs)
• Focus on youth and social roles
• Seamless service across CAMHS/adult

103
The early intervention team

• Based on assertive outreach model
• 115 case ratio 120 max per team
• For 1M population 4 teams

104
Work andtraining
Low dose/ atypical medication
Substance misuse
Interventions
Monitoring for depression and suicidal thinking
Relapse prevention
Personal and Family adjustment
105
The Birmingham Early Intervention Service

• Initiated1989
• Adopted Outreach model1995

Sustained intervention over 3 years emphasising
social inclusion, social networks and individual
and family adaptation to psychosis
106
The EIS partnership
Focus on Regeneration
Focus on communities
Focus On Training
Child and adolescent mental health services
107
Birmingham

• Population 1,200,000
• Mean Jarman Index 18
• Multi-ethnic
• Incidence 50 per 100,000 / year in inner city

108
Wheres Birmingham?
109
(No Transcript)
110
Birmingham Early Intervention
4 EIS Outreach Teams
Early detection team EDIT
3 youth respite Units
Youth treatment program
EPOS Big EDDIE
REDIRECT
111
Assertive Outreach

• Mobile intensive intervention team model
• Service accessible,7 days a week, 365 days
• Case managernurse,S/W supported by assistant
  case managers from non-stat partner
• Flexibility and availability
• 115 staff-client ratio

112
(No Transcript)
113
(No Transcript)
114
(No Transcript)
115
Maintaining Engagement

• Accessible
• Low stigma settings
• Provide what young people want

116
Low stigma channels
117
What young people value and want..
118
(No Transcript)
119
Community Respite Units
5 place homes in community setting
Jointly managed with black housing agency
Keyworker uses respite as resource to manage
crisis
120
(No Transcript)
121

• Reducing DUP
• Working with at risk youth
• Community partnerships
• Anti-stigma campaigning

122
Preventing or delaying transition to psychosis
123
Prevention or delay of psychosisMcGorry et al
2002 Archives of General Psychiatry
making transition to psychosis
Months
124
EDIE A single blind randomised controlled trial
Cognitive Therapy vs. Treatment As
Usual Preliminary Results from 12 months Follow-up
Transition rate in per group
Transition criteria
125
Effectiveness
126
(No Transcript)
127
LEO Trial
All contacts with psychotic symptoms
screened (n319)

• Excluded (n175)
• gt 2 episodes
• Not Sz. Spectrum
• Out of area
• Known elsewhere
• Too old / young
• Lost

(n144)
Met criteria
Control (n73)
LEO (n71)
128
Contact at 18 months
In contact Leo vs Other X211.449 df 3 p lt.02
129
LEO ResultsRelapse at 18 Months
plt0.05
130
LEO ResultsPositive Negative Symptoms at 18
Months PANSS (N99)
plt0.05 plt0.01
131
LEO ResultsSocial Functioning at 18 Months GAF
(N98)
plt0.01
132
The Danish OPUS Trial A randomized controlled
trial of integrated psychiatric treatment for
first episode psychotic patients
British Medical Journal, Sept 16 2005
Merete Nordentoft, Bispebjerg Hospital,
Department of Psychiatry, 2004
133
(No Transcript)
134
Hospital admission and use of bed days during the
first year
  Integrated Standard Sig.
(N274) (N265)   Bed days first y, mean
61 82 lt0.05 Bed days second y, mean 27 35
0.12
Merete Nordentoft, Bispebjerg Hospital,
Department of Psychiatry, 2004
135
Proportion of patients with marked or severe
symptoms after one and two year
136
(No Transcript)
137
Base-Case Results (McCrone, Dhanasari, Knapp 2006)
138
Comparison of LEO vs. Estimate of Standard
Services Costs in First Episode Psychosis(2003
figures)
Annual NHS Costs
Based on ratios from Agustench Cabases
(2000) and from estimates by Guest Cookson
(1999) adjusting for 3 inflation
Total standard NHS cost (estimate) Total
26,851 over first 2 years
NHS Cost per patient per year
LEO costs per patient Total of 15,985 over
first 2 years
OASIS costs per patient Total of 3,375 over 6
months Saving of 38 (control costs 5,485)
Savings/patients in LEO in 2 years 10,866
(40.5 less than standard NHS costs)
(Power et al, 2004)
139
EDEN
The National EDEN project
DUP, service configuration and outcome

(Evaluating the Development and Impact of Early
iNtervention services in the West Midlands)
First-Episode
PSYGRID
E-science Grid
140
The National EDEN sites
Lancashire Wirral 5 teams (Marshall/Lewis/Sharma
)
Birmingham 4 teams (Birchwood/Lester)
East Anglia 2 teams (Jones/Fowler)
Cornwall 1-2 team (Amos/Harrison)
141
(No Transcript)
142
(No Transcript)
143
Prevention? The new epidemiology of psychosis

• Incidence of psychosis not fixed
• Urbanicity (Van Os Pederson)
• Material deprivation
• Social fragmentation (Allardyce)
• Social integration vs marginalisation (AESOP JP
  Selten)

Mcgrath, J (2007) The surpisingly rich contours
of schizophrenia epidemiology Arch Gen Psychiat
144
Birmingham Youth Health
Focus on Regeneration
Focus on communities
Focus On Training
Child and adolescent mental health services
145
(No Transcript)
146
The early course of schizophrenia
Hafner et al.,
(Mannheim ABC study)
DUI
DUP
147
The evidence base for early intervention?

• Growing understanding of interaction of
  psychosocial risk factors and continuum of
  vulnerability
• Majority of FEP have prodromal decline.
• DUP is 12months robustly linked to early
  outcome.
• Disability plateaus by 3 years
• Outcome at 3 years predicts outcome at 15.
• Suicide risk highest lt5yrs of onset.

148
Re-writing the textbooks New epidemiology of
psychosis

• Urbanicity
• Material deprivation
• Social fragmentation
• Social integration vs marginalisation

149
(No Transcript)
150
Why is psychosis X4 more frequent in the
inner-city?
Rate of first episode psychosis
Social fragmentation
151
(No Transcript)
152
(No Transcript)
153
(No Transcript)
154
(No Transcript)
155
(No Transcript)
156
(No Transcript)
157
DUP and early outcome
The Critical Period
158
Source Marshall et al, Arch Gen Psychiat, 2005
159
Brunet and Birchwood, in submission
160
(No Transcript)
161
Early Detection and Treatment of Psychosis
The REDIRECT trial

• A cluster randomised trial in primary care
• Helen Lester and Max Birchwood

162
70 GP Practices
Early Detection Training
Detection as Usual
Three year standard treatment/service protocol
163
Early trajectories predict long term trajectories
The Critical Period
164

The mother of all first episode follow up studies
165
The incidence cohorts
766
DOSMeD
205
RAPyD (disability study)
Invited cohorts
100
Chennai Hong Kong
100
Total
1171
166
Aims

• Describe long term outcome
• Predictive strength of baseline and short term
  course

167
Predicting Outcome at 15 years

• Symptoms(GAF-S)
• time psychotic(0-2yrs)
• Centre

• Disability(GAF-D)
• time psychotic(0-2yrs)
• Centre
• Drug use

168
The risk of relapse(s) is high within first five
years
The Critical Period
169
(No Transcript)
170
(No Transcript)
171
Risk factors for relapse
O.R.
Medication non-adherence
4.89 (2.4-9.6)
Poor adolescent functioning (PAS)
1.57 (1.02-2.4)
172
The plateau of disability
The Critical Period
173
SOCIAL ADJUSTMENT OVER 13 YEARS
1
1
Nottingham DOSMeD
174
Predicting long term social disability in
schizophrenia (RAPyD)

• Wiersma et al, 2000

Psychological Medicine, 30,1155-1167
175
RAPyD

• Prospective study of social disability (WHODAS)
• Incidence cohort , 6 European centres
• Assessed at 1,2,15 years.

176
Prediction of Social Functioning(SF) at 15 years
Beta p
Gender
-0.09 0.08 Age
-0.05
ns Type of onset
0.18 0.03 SF-onset
0.15
0.01 SF-1year
0.14 0.07 SF-2year
0.36
0.00 Chronic vs remission pattern
0.06 ns Multiple R
0.57R

0.32
177
The early phase is a high risk time for suicide
The Critical Period
178
Suicide by time since onset Dutch incidence
cohort (n82)
1
lt5 years
7 (8.5)
gt5 years
2 (2.4)
Total
9 (11)
1 Wiersma et al,1998 Schiz Bull
179
Reasons to be cheerful

• Its a massive bottom-up service reform
• Its government policy
• Theres gt120 teams in the country
• The scientific rationale is solid
• EI works and pays for itself in a year