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Early Intervention: The International Perspective Paddy Power

Early Intervention: The International Perspective Paddy Power. “A Stitch in Time Saves Nine”. Development of Early Psychosis Programs. Melbourne, mid-80’s Buckinghamshire, mid-80’s North Birmingham UK early 90’s Germany, 1990’s (research1970’s) USA & Canada, early 90’s

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Early Intervention: The International Perspective Paddy Power

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  1. Early Intervention:The International PerspectivePaddy Power “A Stitch in Time Saves Nine”

  2. Development of Early Psychosis Programs Melbourne, mid-80’s Buckinghamshire, mid-80’s North Birmingham UK early 90’s Germany, 1990’s (research1970’s) USA & Canada, early 90’s Scandinavia, mid-90s Switzerland mid - 90s Amsterdam, late 90’s Australia late 90’s UK 1999/2000 Far East & South East Asia, 2001 Networks: IEPA & European FE Schizophrenia Network

  3. Types of Early Intervention Model • Option 1: Basis? (CAMHS, Adult, 1° Care, Youth service) • Option 2: Service model? (Specialist vs generic) • Specialist EI services • Stand alone EI service • Hub and Spoke model • Piggy-back supplementary EI model • Tertiary consultation EI services/clinic • Generic Based Services • Top up with embedded EI worker/s • Top up with EI training and clinical guidelines • Research based interventions • Option 3: Degree of community integration • Public health promotion campaigns • integration with social services, education, employment, housing, A&D services, service user agencies

  4. Aims of an Early Intervention service • Reduce delays (& DUP) by: • promoting early detection and collaborative engagement in the community • Optimise assessment & diagnosis by: • Comprehensive Bio/psycho/social assessment • Maximise recovery by: • providing integrated bio/psycho/social community Rx • focus on functional as well as symptomatic factors • addressing co-morbidity and treatment resistance early • Prevent relapse by: • ensuring assertive followup and psychoed. during critical period

  5. Intervening to Maximise Recovery & Prevent Relapse Normal development Early intervention Prodrome Functioning Assertive follow-up Community Team First episode of psychosis 2nd episode of psychosis 16 20 24 Age

  6. Optimising Inpatient Care and Treatment in Early Psychosis? Normal development Prodrome Functioning First episode of psychosis 2nd episode of psychosis FEP Inpatient services 16 20 24 Age

  7. Intervening to reduce the Duration of Untreated Psychosis (DUP) Normal development Early intervention Functioning Prodrome First episode of psychosis Early detection & Crisis Assessment Team 2nd episode of psychosis 16 20 24 Age

  8. Intervening in the Prodrome Phase of Early Psychosis Prodrome clinic Normal development Early intervention Prodrome Functioning First episode of psychosis 2nd episode of psychosis 16 20 24 Age

  9. Configuration of LEO Service Primary Care psychotic prodromal OASIS LEO-CAT Prodrome clinic Early detection & crisis assessment team 2 year follow-up LEO Inpatient Unit LEO Community Team

  10. Canada’s Early Intervention Services • Newfoundland • N&L EPP • British Columbia: • EP Initiative of British Columbia • EPIVMHC,Victoria • Vancouver • EPIP, White Rock • Quebec: • Levis • Montreal • Quebec City • Alberta: • EPT&PP, Calgary (930,000) • Nova Scotia: • NSEPP • Halifax - • Saskatchewan: • EIPP, Saskatoon • Ontario: • PEPP, London • FEPP, Toronto • Psychotic Disorders U., Hamilton • Ottawa FEPP • KPP&TP, Kingston • Key figures: • Jean Addington • Bob Zipursky • Ashok Malla • Lili Kopala

  11. Early Psychosis Programs in the USA • Portland, Maine • PIER service (McFarlane) • Salem, Oregon: • Early Assessment & Support Team (EAST) (pop 600,000) Managed care funded • Yale, New Haven: • PRIMHE (T. McGlashan) • Bethseda, MD: • NIMH research:(Wyatt etc) • New York: • Prodrome (Cornblatt) • Pittsburg: • EI program (Keshevan) • LA California: • UCLA (Ventura, Neuchterlien etc) • N. Carolina: • FEP & prodrome studies (Lieberman)

  12. New Zealand’s Early Intervention Services New Zealand National Early Intervention Group • Auckland: EPI Centre, Kari Centre, Taylor Centre, Manaaki CMHT - FEP, St Lukes FEP, Hartford House EPI, Campbell team Lodge EI team • Wellington: Wellington EI service (400,000) • Christchurch: Tatara House EIP service (380,000) • Dunedin: Aspiring House EI service (150,000) . . . . .

  13. Early Psychosis Programs in Australia National Early Psychosis Project (based at EPPIC) • Queensland: • Uni of Brisbane studies • New South Wales: • YPPI service, Gosford • EP program, Marouba • EP program, North Sydney • EPIP-SWAHS, Liverpool • EPIC, Penrith • Western Sydney FEPP . . . . • Western Australia: • First Psychosis Liaison Unit, • Bentley • EPOES, Fremantle • EEPP, Rockingham • /Kwinana . . • ACT: • Canberra EI service . . • South Australia: • Noarlunga EP Program • Victoria: • EPPIC • Dandenong • EP Program, Alfred Hosp. • Central East EP Project

  14. EPPIC service Western Region of Melbourne (pop = 850,000) • 4 sectors • Inner West: (145,000) • North West: (266,700) • Mid west: (208,000) • South West: (237,600) • (Each sector has 20 CCU beds for long-stay patients) 21 Western Melbourne 24 EPPIC 16 21 24 South west Area = Acute adult = EPPIC beds

  15. Overview of Mental Health Services For Kids & Youth Western Region of Melbourne (800,000) Youth Assessment Team Prodrome PACE Clinic Non-psychotic Ages 15 -19 Psychotic Ages 15-30 Older Adolescent Service (follow-up to age 19) EPPIC (18 month follow-up) Acute Inpatient Care Day Group Program Family work Cognitive Therapies Outpatient Case Management Intensive Outreach Support

  16. PACE Treatment Trial(Phillips et al 2000, McGorry et al, 2002)(n= 59) Transition Rate to Psychosis • RCT of CBT + low dose Risperidone X 6/12 versus supportive psychosocial therapy (NSI) • Both groups ~ 50% received SSRIs • Those fully compliant with Risperidone afforded greatest protection at 6 months (5.6%) and follow-up after meds ceased • 2 suicides in refusal group (n=33) (N=28) 35.7% (N=31) 9.7% P = 0.026 Fisher Exact test

  17. South East Asian Early Psychosis Network South Korea Tokyo, Osaka Hong Kong: EASY - 4 teams cover 7M (Eric Chen et al) Singapore: EPIP 1 team covers 4 M (S. Chong et al) Palau, Miconesia (South Africa)

  18. Swiss Early Psychosis Programs • Bern: • Uni Hosp. of Social & Comm. Psych. • (Gekle) (Merlo - moved to Geneva) Geneva & Zurich: Swiss Early Psychosis Project SWEPP (Simon, Umbricht & Merlo) • Basil: • Uni Hosp. Basil: Basil FEPSY screening study (Gschwandtner et al)

  19. German Early Psychosis Programs • Dusseldorf: • RCT of psychological Rx in FEP (Klinberg) . . • Heidelberg: • Heidelberg Early Adolescent & Adult Recognition & Therapy Centre for Psychosis (HEART) EI service since since 1994 (Franz Resch et al) . • Cologne: • Cologne early Recognition study (Klosterkotter, Schultze-lutter et al) . . . • Bonn: • Prodrome Rx (Hambrecht et al) • Vienna, Austria: • Adolescent EI program at University Hosp. of Vienna (Amminger, Edwards) • Mannheim: • Central Insitute of Mental Health • (Hafner, Maurer et al)

  20. Scandinavian Early Psychosis Services • Finland: • Turku: Detection of early Psychosis project • (Suomela et al) • Norwegian Services: • TIPS - Roskilde/Stravanger • (Larsen, Johannessen etc) • UNA-projektet, Oslo • EOP, Skien • Swedish Services: • Parachute Project (1.5 M), Stockholm • Sodertalja Psykiatriska Sektor, Sodetalje • TUPP Project, Stockholm (Cleland) Control DUP median (weeks)

  21. OPUS study (Nordentoft et al ) RCT of Assertive Community Follow-up in First Episode Psychosis 582 patients (18 - 45 year olds) with non affective first episode psychosis Mean Bed days/patient % cases with mod/severe symptoms (p <0.05) The cost saved for in-patient care/year = €600,000 for 100 patients = wages of 10 staff Merete Nordentoft, Bispebjerg Hospital, Department of Psychiatry, 2004

  22. Dutch & Belgian EI Programs • Netherlands: • Academic Medical Centre (Don Linszen) • University of Maastricht: NEMESIS (Van Os, J.) • University Med Centre, Utrecht (Dutch Prediction of Psychosis Study- DUPS) • Belgian Projects: • PECC (Janssen-Cilag) • Other European Projects: • European Prediction of Psychosis (EPOS) study (6 centres: Birmingham, Amsterdam, Cologne, Turku, Santander, Dannstadt) • Dublin: SJOG Hospital (E. O’Callaghan) • Bordeaux: (Helen Verdoux) • Barcelona, Madrid, Santander: 4 prodrome research programs • Lisbon: planning EI service • Eastern European, Russian & Middle East: research programs & plans for services

  23. Early Intervention Services in England • Edinburgh • YPU @ Royal Edinburgh Hosp. • Edinburgh High Risk study(E. Johnstone) • Glasgow: • EI service (A Blair) • NHS plan: PIG • IRIS: Newcastle declaration • 50 teams by 2005 • -23 EI teams to date • EI teams include: • North Birmingham EI service • LEO & OASIS service • Plymouth service • Manchester • Tower Hamlets • ETHOS • COAST • Sheffield EI service • STEPS, Poole £1M

  24. RCT of LEO Community Team Engagement with Services at 18 months (N=138) % Clients still attending at 18 months At 6 months: African Caribbean engagement: = 89% vs 27 %: LEO vs Control p<0.02 (Craig et al, 2004)

  25. Adherence to prescribed antipsychotic medication over 6 months 1 Proportion taking medication 0.61 LEO 0.5 0.28 OTHER 0 1 3 4 5 6 2 Months post randomisation (Craig et al, 2004)

  26. LEO Trial ResultsRelapse at 18 months, from full or partial recovery (N=122) • Significant better improvements @ 18 months follow-up:: • Positive and Negative symptoms • Insight & treatment adherence • GAF score • Satisfaction with services % of clients who relapsed p<0.05 (Craig, Garety et al, 2004)

  27. Hospitalisation rates for LEO patients LEO Ward opens (n=73) (n=71) (n=63) (n=73) (n=156) Control group (standard care) LEO Trial Group Inter study LEO group % LEO patients admitted 1st LEOCAT LEOCAT Trial 2000 - 2001 - 2003 - 2004-2005

  28. Discharges Destinations after 2 years Follow-up with LEO (n=269) • 136 LEO clients discharged to date: • 37 to Out of Area services • 17 overseas • 20 additional clients overdue discharge • 14 waiting CMHT transfer

  29. Economic Benefits of Intervening Early:Comparison of LEO vs. Estimate of Standard Costs in First Episode Psychosis(2003 figures) * Based on ratios from Agustench & Cabases (2000), estimates by Guest & Cookson (1999) and adjusting for 3% inflation for 2003 NHS Cost per first episode patient/year Total standard NHS cost(estimate) Total = £26,851 over 2 years LEO costs (including LEOCAT): Total of £15,985 over 2 years Savings with LEO = £10,866 (40.4% less than standard NHS costs)

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