Early Intervention Services in Wales?

1. Early Intervention Services in Wales? Dr. Euan Hails Clinical Lead Psychosis and Recovery & National FEP Lead, Wales

2. Aims and acknowledgements: • To look at evidence for EI Services • To touch on service provision and developments in Wales • To acknowledge work of Rethink England and to thank them for some slides! • To acknowledge work of Prof ShônLewisManchester Uniand to thank him for some slides! • To acknowledge work of Prof Jo SmithWorcester and to thank her for some data! • To acknowledge work of all involved in FEP/EIP developments across Wales. • To acknowledge work of 1000Lives Plus Wales.

3. The Schizophrenia Commission www.rethink.org

4. Sir Robin Murray, Chair The message that comes through loud and clear is that people are being badly let down by the system in almost every area of their lives. www.rethink.org

5. Early Intervention Services “the great innovation of the last 10 years” “the most positive development in mental health services since the beginning of community care.” www.rethink.org

6. Findings from the Schizophrenia Commission ...nowhere else have we seen the constant high standards, recovery ethos, co-production and multi-disciplinary team working. www.rethink.org

7. Findings from the Schizophrenia Commission Those giving evidence emphasised the value base of early intervention services – their kindness, hopefulness, care, compassion and focus on recovery. They provide treatment in non stigmatising settings, seek to maintain social support networks while an individual is unwell, take account of the wider needs of the individual and deliver education as a core part of the service to families, staff and service users. www.rethink.org

8. Evidence A recent systematic review and meta-analysis suggested that specialised First Episode Psychosis programmes can significantly reduce the risk of relapse when compared to usual treatment (Alvarez-Jiménez et al. 2011). www.rethink.org

9. Evidence Early Intervention Services have a positive impact on the retention and gain of competitive employment. McCrone et al. (2010) www.rethink.org

10. Evidence 35% of people in EI services are in employment 12% of people in standard care are in employment McCrone et al. (2010) www.rethink.org

11. Evidence Service model is based on evidence that suggests an association between the duration of untreated psychosis and overall prognosis. (Marshall et al. 2005). www.rethink.org

12. Standard care outcomes in early psychosis

13. Specialist care outcomes in early psychosis Worcestershire EIS Outcome Data (Smith 2006: Smith 2009)

14. Why is Early detection important? • A delay in spotting that a young person might be developing a 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, lack of insight, family problems, poverty, physical health problems, trauma, increased depression and suicide

15. Why is Early detection 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)

16. Duration of Untreated Psychosis(DUP) and National Guidelines • Reducing DUP is a specific target in national mental health performance measures (WG, 2009) • MH services are required to reduce DUP to 3 months and not exceed 6 months (WG, 2009) • HOWEVER, these figures relate to ‘genuine’ psychosis, not to ‘pre-psychotic’ presentations

18. 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

19. Aims of HDUHB IAPT Project (depression, anxiety and psychosis) For patients entering our service to receive evidence based psychological therapies delivered by mental health professionals who are competent in their use. For our service to be NICE compliant. NICE guidelines; Depression, Anxiety, Schizophrenia and Bipolar Disorder. 19 Psychosis Pathway Hywel Dda UHB

20. Based on an understanding of the typical course of psychosis, what should a care pathway for people with psychosis be aiming to achieve? • To delay or prevent psychosis emerging • To reduce the duration of untreated psychosis (DUP) • To provide optimal interventions to promote social and clinical recovery • To prevent or minimise relapse • To offer services that promote individual recovery and wellbeing Psychosis Pathway Hywel Dda UHB 20

21. A revised care pathway for psychosis should achieve: Better detection and monitoring of people with at risk mental states for psychosis (ARMS) Lower rates of transition to psychosis for people with ARMS Reductions in DUP for people with first episode psychosis Higher rates of social and clinical recovery in early and established psychosis Prevention or minimisation of relapse in early and established psychosis Improvement in long term physical health HB to offer services that promote individual recovery and wellbeing

22. 1. Pre ARMS Phase - Education about Psychosis 3. Early Intervention after onset of psychosis (EI) Typical Course of Psychosis (Larsen et al 2001) Early Intervention in Psychosis Pathway 2. Early Detection & Interventionin the ‘at-risk mental state’ (ARMS) phase (Early Detection) 4. Maintaining outcomes beyond EI service involvement: in primary care/GP Service Psychosis “DUP” Premorbid phase Very early symptoms Psychotic symptoms Treatment & Recovery Relapse? Primary Care Early detection of psychosis and relapse/EI for bodies and minds Adolescence to Adulthood Transition Psychosis Pathway Hywel Dda UHB 22

23. Secondary Care Established Psychosis Services Pathway - Enhancement of patient’s recovery and wellbeing by offering NICE Guidelines nominated care. 5. Maintaining outcomes beyond EI service involvement: in secondary care, AOT, CMHT, In-patients, R&R, CRHT, CIST, psychological services 6. Specialist intervention continue in established psychosis services promoting recovery and wellbeing • 8. Future support + future directions: • 3rd Sector • Vocational Rehab • Housing • Education 7. Maintaining outcomes in Established Psychosis service: AOT, CMHT, In-patients, R&R, CRHT, CIST services – return primary care/GP Service – recovery and wellbeing. Ongoing secondary care involvement Ongoing psychotic symptoms Treatment & Recovery Ongoing Secondary/Primary Care involvement Treatment & Recovery Relapse? Primary Care or Secondary Care Delivery of CBTp, BFI, Art Therapy, A-typicals, care-coordination, interface working to promote recovery and wellbeing Early Psychosis to Established Psychosis Transition Established Psychosis 23

27. With thanks to:IEPA clinical practice guidelines for ARMSProf ShônLewisUniversity of Manchester UK

28. At risk mental state: Yung et al 1998 • Attenuated positive symptoms • subthreshold for severity • Brief limited intermittent psychotic symptoms • subthreshold for duration (<1 week) • Schizotypal personality or first degree relative with psychosis plus recent functional deterioration • Seeking help

29. High risk of acronyms • PACE • PRIME • EDIE • RAP • FETZ • TOPP • PIER • OASIS • EPOS • CARE • NAPLS • SPAM • Society for Prevention of Acronyms in Mental health

30. Rates of one year transition ARMS to psychosis (adapted from Lisa Phillips et al 2005)

31. IEPA clinical guidelines for early psychosis • Formulated Copenhagen 2002 • 29 authors A-Y • Published 2005 • To be updated 2008 • Covered • ARMS • First episode • Recovery (6-18 months) and critical period phase IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

32. Prevention in early psychosis • Three targets for preventative interventions in early psychosis • Prepsychotic phase • Initially untreated psychosis • First episode IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

33. General statements • Early identification will reduce burden • May improve long term outcomes • Public education important • Careful, low dose drug treatment in first episode • Psychosocial treatments important in promoting recovery • Users and families engaged in developing better treatments IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

34. The prepsychotic period: clinical guidelines • At risk mental state needs to be considered in young people with deteriorating functioning or unexplained agitation IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

35. The prepsychotic period: clinical guidelines • Help seeking people with ARMS need to be engaged and assessed and offered • Regular monitoring and support • Specific treatment for depression or substance use • Psychoeducation and help to develop coping skills • Family education and support • Information about risks of psychosis IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

36. The prepsychotic period: clinical guidelines • Care offered in a low stigma environment • At home; primary care; youth-friendly office-based setting • Antipsychotic drugs not usually indicated • Exceptions might be risk of suicide or violence, or rapid deterioration • If used, regard as therapeutic trial for up to 6 weeks • If help declined, consider support from friends and family IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

37. Issues for ARMS interventions • Safety and acceptability • Efficacy and effectiveness • Availability and cost • What is the therapeutic target? • Prevention versus treatment • Ethics • Of treatment; Of non-treatment • Population impact IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

38. Issues for ARMS interventions • Refinement of risk estimates • Modifying risk and protective factors • Developing a clinical algorithm • Psychological intervention first? • Drug treatment second? • How long for? IEPA writing group Br J Psychiatry 2005 187 s48 s120-124

39. Which psychological intervention? • Cognitive therapy (Morrison et al, 2006; Ruhrman et al, 2007) • Also? (from psychosis literature) • Family intervention • CT for relapse • Motivational interventions • Cognitive remediation

40. Which drug treatments? • Antipsychotics? • Appear effective • RCT data with risperidone; olanzapine; amisulpride • BUT risks from side effects • Doubtful acceptability for many • Antidepressants? • Anecdotal evidence

41. EDIE trial: ResultsTransitions to psychosis at 12 months Morrison et al, 2004

42. Improving monitoring and interventions in physical health problems of people with early psychosis

43. What happens when people with psychosis develop physical disorders?Five-year survival rates Hippisley-Cox J et al (2006)A comparison of survival rates for people with mental health problems and the remaining population with specific conditions.Disability Rights Commission. Equal treatment: closing the gap, July 2006

44. What we specifically suggest… • For the local EIP spoke staff to make themselves available on a regular agreed basis to discuss and screen potential cases/ARMS cases. • For people with psychosis - the local EIP spoke will support and case manage these people in primary or secondary care as appropriate with GP’s (in primary care) and responsible clinicians (in secondary care). • For people with ARMS - psychological therapists working as part of the local EIP spoke will offer CBT, monitoring and psychotherapeutic support in PC to prevent or delay psychosis emerging. • If ARMS patients become psychotic- they will be case managed in primary or secondary care by the local EIP service as appropriate. A revised care pathway for psychosis is in development which will support this approach.

45. Contact: • Dr. Euan Hails Euan.hails@wales.nhs.uk