Early Intervention in Psychosis: the NSF and beyond

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Annual Norwegian Early Intervention
ConferenceSeptember 2nd 2008 The NIMHE
National Early Intervention in Psychosis (EIP)
ProgrammeThe Development of EIP in the UK
Dr Jo Smith and Dr David Shiers NIMHE Joint
National Early Intervention Programme Leads



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An English picture

• The needs of families coping with early psychosis
• EI development in the UK
• What triggered its development?
• Where has it got to?
• Are we here yet?
• Lessons learnt?

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Was this story unique?
Families concerns ignored 50 lost to
follow-up at 12m Danger ?10 lifetime suicide
risk (2/3 in first 5yrs)
Treatment delays 12-18m Crisis response the
rule - 80 hospital admission - 45
police involved - 50 mental health act
- Hugely traumatic
GPs are key pathway players

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marooned to some backwater?
our overwhelming feeling was of an opportunity
missed - to what degree she has been needlessly
disabled by those first four years of care well
never know Mother 2002

• Stagnation in pessimistic service
• Relapse and remission
• Dis-ease
• Stigma social exclusion
• Unfulfilled lives

cant get a job, cant get a girlfriend, cant
get a telly, cant get nothing its just
everything falls down into a big pit and you
cant get out Hirschfeld, 2002
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Does it have to be like this?

• St Vicenzo in Northern Italy 1989 a model
  of health improvement. WHO declaration that
  transformed diabetes care
• Transformational outcomes
• Attract good practice
• Raise expectations of consumers
• IRIS Rethink ? political pressure in UK
• Early Psychosis Declaration key outcomes for
  young people with first episode psychosis and
  their families

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DELAYS COERCION
STIGMA PREJUDICE
DISSATISFACTION
SOCIAL EXCLUSION
PESSMISTICSERVICES
ISOLATED IGNORED FAMILIES
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IMPROVE ACCESS ENGAGEMENT
RAISE COMMUNITY AWARENESS
EARLY PSYCHOSIS DECLARATION
PROMOTE RECOVERY AND ORDINARY LIVES
TEACH PRACTITIONER COMMUNITYWORKERS
ENGAGE AND SUPPORT FAMILIES
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Duration of Untreated Psychosis less than 3 m
90 satisfied with employment, educational,
social attainments
Effective treatment after no more than 3 attempts
to seek help
BLACK BOX
The use of involuntary treatment less than 25
Suicide rates less than 1
All 15 year olds able to understand and know how
to seek help re psychosis.
First contact with families or other supporters
within a week
90 of families feel respected and valued as
partners in care
Consumers confident that generalists
specialists can deal effectively with early
psychosis
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Early Psychosis Declaration

• We need committed people, we need good-will
  people, we need grass-roots people.
• this is a task for us all, each one with their
  possibilities and capabilities, but all together
  

A collaboration between NIMHE / Rethink, IRIS,
the World Health Organisation and the
International Early Psychosis Association
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It doesnt have to be like this

• Early intervention in Psychosis is a
  paradigm of care for young people with a first
  episode psychosis and their families based on
  research and comprises three concepts
• Early detection of psychosis
• Reduce the long duration of untreated psychosis
• Importance of the first 3-5 years following onset
  (critical period) for later biological,
  psychological and social outcomes

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Early Intervention Service Aims

• Provide information
• Offer support to families
• Provide pharmacological, psychological and social
  interventions to support recovery in the least
  stigmatising and restrictive settings
• Prevent development of secondary problems such as
  depression and suicide
• Prevent further episodes
• Liaise with education, work, health, youth and
  community support agencies to support return to
  social, educational and work functioning

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Initial Policy support

• NSF Adult Mental Health (1999)
• Early intervention in psychosis
• first appears as a policy commitment
• NHS National Plan (DoH 2000)
• By 2004, all young people who experience a first
  episode psychosis will receive early and
  intensive support
• Planning and Priorities Framework (2003-2006)
• DUP less than 3 months
• Support for first 3 years
• CAMHS Target and Childrens NSF (DoH 2003)
• Comprehensive EI services by 2006

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Early Intervention Policy Implementation
Guide (PIG) Criteria

• Intervention over 3 years
• Accessible to 14 to 35 years old
•   Active monitoring of individuals at high risk
  of psychosis or with suspected
• psychosis for a minimum of 6 months
•   Caseloads of 15 cases per case manager
• Multidisciplinary staff mix with specialist
  skills/experience in work with
• adolescents, family intervention, low dose
  medication, CBT, relapse prevention and
• substance misuse interventions
•   Systems in place to cover out of hours and
  weekends
•   Strategy for early detection and engagement of
  high risk and suspected psychosis
• cases
• Monitors Duration of Untreated Psychosis,
  engagement rates, relapse rates, hospital
• readmission, suicide and parasuicide,
  education and employment functioning.

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NIMHE/Rethink National EI Programme

• Early Psychosis Declaration at its heart
• Infrastructure to support EI implementation
  regional networks, tools and resources
• Provide leadership Navigate obstacles

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Early Psychosis Declaration

• Regional hothouses to address aspects of EPD
  e.g.
• Support the voice of young users and families
• Encourage local partnerships necessary to deliver
  service change to local communities
• Schools On the Edge drama production and
  Back from the Edge educational pack
• EPD self assessment toolkit
• EI as a social movement
• Evaluation of the National EI Programme
• Link to NHS Institute

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Establish a sound infrastructure to support EI
implementation

• Knowledge management
• EI knowledge community
• Framework for research dissemination, practice
  exchange and training
• National EI Service Mapping exercise
• Establish regional EI networks, tools and
  resources
• Conduit for feedback between EI networks and DH
  centre
• EI Training CD rom
• Practice guidance papers
• Promote Primary Care pathways
• Competency for EI in new RCGP curriculum
• White Water Rafting service redesign tool
• Early detection guidance and toolkit

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Provide leadership

• Profile and prioritise EI on national policy
  agendas
• Ensure continuation / consolidation of investment
  in EI by challenging disinvestment
• Profile EI services in national documents eg 10
  High Impact Changes
• National research seminars to profile current UK
  EI research
• Establish international profile for EI
  development in the UK at IEPA and other
  international conferences, international
  collaboration on research and practice tools

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From margin to mainstream intensification
Changing practice

• Secure
• IEPA and WHO
• Support

St Vincents Model Launch of Newcastle
Declaration
NIMHE/Rethink EI development
programme Implement the declaration
N S F
Inner rage IRIS Guidelines big
idea Policy
EI service development in the UK From counting
teams To counting cases To counting outcomes
First episode research First EIS EPPIC
International Early Psychosis Declaration
off the ground
beyond illness to health
get organised
1986 / 1992 1995 / 1999 2002
2004 2008/9
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From Counting Teams
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Sig.Growth in EI Teams NationallyLondon MiData
set illustration(Fisher et al 2007)
2005
2007
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To Counting Cases
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Continuing Policy Support

• DH EI Recovery Plan 2006/7 (DH 2006)
• Original 2003-2006 trajectories to provide EI to
  22,500 patients by December 2006 was off-course
• EI Recovery Plan to provide EI to 7500 new
  patients in 06/07 to put EI development back on
  target
• 2007/8 NHS operating framework continuing
  priority...so that EI services in place in all
  areas.
• 2008/9 NHS operating framework EI still there

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Early Intervention Provision across England (year
end caseload figures)
2 teams 24 teams 41teams 109
teams 127 teams 160 teams 145services
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Reflection on the Status Quo

• Simply commissioning EI teams and meeting
  caseload targets are necessary enablers but not
  sufficient in themselves
• its the quality of service provision that really
  makes the difference

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To Counting Outcomes
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Clinical Effectiveness Outcome Data
from Worcestershire EIS (Smith, 2006)
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UK and International EI outcomes Research

• EarIy Intervention
• London Mi-Data pan-London research network
• First Episode Research Network (FERN)
• EDEN and National EDEN
• PSYGRID
• Early detection
• EDIE and EDIE2 trial
• EDIT
• REDIRECT
• Burgeoning international evidence base
• (eg. Addington, 2007, McGorry 2007)

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Invest to Save Argument EI Cost Economic Data
(McCrone, Dhanasari, Knapp 2007)
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Paying the Price The cost of mental health care
in England to 2026
McCrone P, Dhanasiri S, Patel A, Knapp M,
Lawton-Smith S Kings Fund 2008

• Early intervention services for psychosis have
  also demonstrated their effectiveness in helping
  to reduce costs and demands on mental health
  services in the medium to long-term, and should
  be extended to provide care for people as soon as
  their illness emerges.

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Potential Savings from Expanding EI services in
England over next 20 yearsPaying the Price The
cost of mental health care in England to
2026McCrone P, Dhanasiri S, Patel A, Knapp M,
Lawton-Smith S Kings Fund 2008
National Coverage by EI teams
5000 saved per case/year with EI teams 5,500 new
cases of Schizophrenia/year (Fearon et al, 2006)

100 coverage
90 coverage
Annual national savings ( Million)
80 coverage
70 coverage
60 coverage
Assumes 50 coverage in 2008
Similar pattern with Bipolar Disorder
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Challenges beyond current UK EI policy
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Typical Course of Psychosis (Larsen et al 2001)
Early Detection Intervention in the at-risk
mental state (ARMS) phase (Early Detection)
Early Intervention after onset of psychosis (EI)
Psychosis
Maintaining outcomes beyond EI service
involvement
DUP
premorbid phase
very early symptoms
psychotic symptoms
Treatment Recovery
Relapse?
Adolescence to Adulthood
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Equality Issues and Outcomes

• BME communities
• Access for all 14-35 year olds with a FEP
• Women with FEP
• Young Offenders
• Individuals with dual diagnoses

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FEP typically commences in young people as do
many of the more serious mental disorders
Victoria (Aus) Burden of Disease Study Incident
Years Lived with Disability rates per 1000
population by mental disorder
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Youth Health Services weakest when they need to
be strongest

• The issue
• CAMHS / adult interface and transition issues
  service centred rather than person centred
• We need
• Partnerships with youth agencies to develop
  comprehensive youth focussed services
• Young peoples inpatient care and crisis
  provision
• Youth sensitive service provision
• Extend the EI Paradigm to other mental health
  disorders that have their onset in youth

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What have we learnt
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From margin to mainstream intensification
beyond policy and a National EI Programme

• Secure
• IEPA and WHO
• Support

St Vincents Model Launch of Newcastle
Declaration
NIMHE EI development programme Implement the
declaration
N S F
EI service development in the UK From counting
teams To counting cases To counting outcomes
Inner rage IRIS Guidelines big
idea Policy
First episode research First EIS EPPIC
International Early Psychosis Declaration
off the ground
beyond illness to health
get organised
1986 / 1992 1995 / 1999 2002
2004 2008/9
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People change what they do less because they are
given analysis that shifts their thinking than
because they are shown a truth that influences
their feelings. (J P Kotter, The Heart of
Change, 2002)
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• Encourage others to see EI
• not as a PROBLEM demanding ever more scarce
  resources
• but as an ANSWER by demonstrating better use of
  resources
• Use and harness three VECTORS of policy, research
  and service/practice development to support and
  progress EI development
• Highlight injustice and encourage a social
  movement approach

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You dont need an engine when you have wind in
your sails Paul Bate 2004