Assessment in First Episode Psychosis

1. Assessment in First Episode Psychosis Manchester Mental Health & Social Care Trust

2. Aims & Objectives • For participants to gain an understanding of the process and content of initial assessments. • To develop an awareness of the components of a comprehensive multi- disciplinary assessment • To provide an overview of additional assessments which might be conducted during the assessment process.

3. Why is Early Assessment Important? • A delay in spotting that a young person might be developing psychosis also leads to delay in getting help and treatment • Such problems include less chance of complete remission of symptoms, an increased resistance to treatments (including medication), increased incidence of compulsory admissions (involving violence), lack of insight, family problems, poverty, increased depression and suicide (Johannessen 2001)

4. Why is Early Assessment Important? • The cognitive and psychosocial damage caused by psychosis appears to occur in the first 5 years. This is often referred to as the ‘critical period’. • If help is not offered in this critical period, a range of long-term problems may develop - the ‘plateau of disability’ (Lieberman 1997) • Treating during the ‘critical period’ can decrease relapse and social disability, limit psychological problems and reduce healthcare costs (McGorry & Jackson 1999)

5. Duration of Untreated Psychosis (DUP) • The longer the ‘DUP’ the more risk of long-term problems (Johannessen et al 2001) • Early intervention has been shown to reduce DUP (Perkins et al 2005) • Earlier detection is a core principle of Early Intervention teams

6. Duration of Untreated Psychosis (DUP) and National Guidelines • Reducing DUP is a specific target in national mental health performance measures (DOH 2003) • MH services are required to reduce service DUP to 3 months and not exceed 6 months (DOH 2003) • HOWEVER, these figures relate to ‘genuine’ psychosis, not to ‘pre-psychotic’ presentations

7. Who might notice? • In two large groups, discuss who might be in a position to notice if a young person was developing the early signs of a possible psychotic illness • List these people on a flip chart • Feedback results to the whole group

8. What might they notice?Behavioural Changes • Losing interest in doing things • Losing interest in the way they look • Changes in sleep - either much less or much more • Seeing less of friends • Having trouble sitting still and relaxing • Eating less (or more) • Arguing more frequently with family and friends • Deterioration in personal appearance

9. What might they notice? Changes in Thinking • Trouble concentrating and ‘thinking straight’ • Thoughts seem more rapid - can’t ‘keep up’ with them • Spending time thinking about new ideas - e.g. religion • Trouble making even simple decisions • Bothered by thoughts they can’t get rid of • Having more trouble remembering things • Thinking that ‘people’ are making fun of them • Thinking that people are checking up on them • Laughing/smiling to themselves, talking when no-one’s there

10. Questions to consider about thinking and beliefs • What are the central beliefs the young person holds? • What specific situations lead to difficulties ? • How much conviction is there in these beliefs? • How much distress do the beliefs cause? • Can the person be distracted ? • How much time is spent thinking about the beliefs?

11. What might they notice? Changes in Mood • Mood gets lower - may feel bad for no reason • Future seems to become more hopeless • Feeling distant from family or friends • Feeling disconnected with surroundings • Feeling guilty, maybe about doing something wrong • Feeling tense and nervous • Feeling worthless and low self esteem • Feeling very frightened for no obvious reason

12. Why do mental health professionals assess mental state? • To provide an understanding of the person • To assist in the judgement of the individual’s level of ability • To provide the foundation for a planned programme of care • To develop a baseline for observing progress over time • To plan service provision • For research purposes

13. Why do mental health professionals assess mental state? • To provide a history and an outline of the persons current life circumstances • To identify current difficulties, problem areas strengths and abilities • It can assist in engagement and provides the opportunity for the person to be involved in their care • It can help to provide an alternative but plausible explanation for the illness • Instils hope as this leads on to active interventions

14. Where does assessment fit into the care pathway? ENGAGEMENT ASSESSMENT PROBLEM IDENTIFICATION FORMULATION CARE PLAN INTERVENTION REVIEW

15. How do professionals assess? • Hearing the persons story in their own words & observation • Semi-structured interviews • Standardised assessments and questionnaires • Self Rating e.g. diaries • Listening to significant others • Genograms and lifelines

16. Listening to the young persons’ story • Some people can find it threatening or at least very difficult to remember their experiences • Experiences of failure should be avoided particularly in the early stages • Clients will be more likely to be responsive to the help offered if a partnership is developed that allows them to have some control.

17. Helping the assessment process along • Establish mutually agreed boundaries at the beginning such as the time you want to spend talking. • Encourage the client to expand on information by the asking the question: Is there anything you would like to add? • Keep questions simple, avoid asking multiple questions and allow the client time to answer • Avoid using complicated terms or jargon

18. Helping the assessment process along • Re-cap on the information you have been given to ensure clarity • If you need to write anything down explain why you are doing this and ask permission

19. Aims of the Semi-structured Interview • To acquire the history behind the illness. Consider what, when, how, where and why. • To ascertain any current risk factors • Elicit any current concerns and the implications or consequences of these.

20. Semi-structured Interviews • To become aware of the presenting symptoms and coping skills • To evaluate physical health status • To gain an insight into social needs and functioning • To ascertain the persons’ past and current quality of life and its effects on others • To consider any issues concerning the client in relation to accommodation or financial needs

21. Exercise • In groups of three - one person to role play Monica, one the support teacher and the other to act as an observer • Read the case study provided • You are meeting Monica to ask her some questions about what has been going on for her recently • Consider how you are going to introduce the process and manage her suspiciousness • Practice this in role play. Following feedback from the observer, change roles

22. Standardised Assessments and Questionnaires • A standardised assessment accurately measures either a population or problem area accurately as it has been proven to be both reliable and valid • There are many standardised assessments so it is important to choose the most appropriate ones. • Standardised assessments might be completed by the client or the professional

23. Standardised Assessments to Assess Mental State Areas that warrant a formal assessment might focus on particular areas: • Psychotic symptoms: KGV; Positive & Negative Syndrome Scales (PANSS); Brief Psychiatric Rating Scale (BPRS).Psychiatric Rating Scale (PSYRATS); Belief About Voices Questionnaire (BAVQ) • Mood: Calgary Depression Inventory(CDI); Beck’s Depression Inventory (BDI); Hospital Anxiety & Depression Scale (HADS). • Risk: Sainsbury’s Assessment and Management of Risk; Manchester Assessment of Self Harm (MASH)

24. Standardised Screening Tools, Assessments & Questionnaires • Substance Misuse: Michigan Alcohol Screening Tool (MAST);Drug Abuse Screening Tool (DAST) Substance Abuse Treatment Scale (SATS);Clinical Drug Use Scale (CDUS);Clinical Alcohol Use Scale (CAUS); • Activities of Daily Living & Function; Social Function Scale (SFS); Canadian Occupational Performance Measure (COPM);Model of Human Occupation Screening Tool (MOHOST) • Family Assessments:Family Questionnaire (FQ); General Health Questionnaire (GHQ);Relatives Assessment Interview (RAI);Knowledge about Schizophrenia Questionnaire (KASI)

25. Assessment • Other areas to assess include: • Relationships and sexual functioning • Physical health, • Interests and activities, • Education,training and employment • Benefits and finances • Accommodation

26. Diaries & Self Reporting • Useful for self monitoring • Can identify the things that help (e.g. “being with a trusted person reduces the distress”) • Gives an idiosyncratic account of the clients’ experiences • Provides more detail which often leads to new ideas about dealing with the problem • Can be used to record psychotic experiences, substance misuse, sleep pattern & activity levels

27. Diaries & Self Reporting • Include dates and times • Consider triggers to changes in mood, incidents, social situation or environmental changes • List any coping strategies that were effective or ineffective • May include associated physical sensations, thoughts or beliefs

28. Gaining Information from Collateral Sources All kinds of people MAY be in a position to recognise potential psychosis in young people: • Families, friends and carers • Teachers and others involved in education • GPs, practice nurses and others in primary care • Police, probation officers, prison officers etc • Youth workers, either professional or voluntary • Neighbours, hostel staff, wardens, domestic staff

29. Genograms • Assists in the understanding of family support system • Helps to understand the relationships between family members • Indicates who would benefit from being included in family interventions • Aids engagement • Can clarify history of mental and physical health

30. Lifelines • Aids engagement • Can be used as an aid to describe stress vulnerability • Assists in the development of Early Warning Signs and Relapse Prevention • Can be used in the process of medication management • Helps to ascertain use of alcohol & drugs • Helps to gain insight into future aspirations

31. Problems in the use of Genograms & Lifelines • They might highlight difficult past memories • They might trigger strong feelings of past relationships & experiences • They may reinforce low self esteem and feelings of inadequacy and loss • They may introduce confidentiality dilemmas • They may increase the development of paranoid ideas

32. Group Exercise • Use the case study from earlier in the session • In small groups list all those areas you might want more information • List the types of assessment you might use to do this • Consider the advantages and disadvantages of each type of assessment • Compare your answers with the larger group as you feedback.

33. Conclusions • Evidence suggests the importance of early assessment for those who have the potential to develop a psychotic illness • Changes in behaviour, thoughts and mood may be recognised by anyone involved with the young person • Assessment should follow the engagement process. Making sense of information discovered during assessment precedes treatment • There are many forms of assessment, from informal observation to formal and standardised styles.