MINDSET IN STAFFORDSHIRE MOORLANDS

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MINDSET IN STAFFORDSHIRE MOORLANDS
NIMHE Primary Care Programme

• Early Intervention in Psychosis needs more than
  just Early Intervention Services
• Dr. Fiona Macmillan Early Intervention lead
• Dr. David Shiers Primary Care Lead

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NIMHE West Midlands
NIMHE Primary Care Programme

• We aim to support a whole systems approach to
  establishing mental health services that could be
  used with confidence by our families, our friends
  and ourselves.

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Two Hats
NIMHE Primary Care Programme

• GP
• Father of a daughter
• with schizophrenia

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Incidence of Psychosis in Primary Care
NIMHE Primary Care Programme

• An average GP in the UK with a list size of 2000
  patients expects to see each year
• 250 new mental health cases
• 5 with severe mental health problems
• 1 with a first episode of psychosis
• and will be responsible at any one time for
• 10-20 registered on his/her list with psychosis
• 30 with psychosis managed solely by GP without
  support
• of specialist care (Kendrick,2000)

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GPs see a FEP at an age when other serious mental
disorders tend to develop
NIMHE Primary Care Programme

• Victoria (Aus) Burden of Disease Study Incident
  Years Lived with
• Disability rates per 1000 population by mental
  disorder

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Primary care has
NIMHE Primary Care Programme

• Knowledge of individual before onset of psychosis
• Knowledge of the family
• Alertness to changes in behaviour and functioning
  which may precede first episode and relapse
• Long term continuity of care
• More accessible and less stigmatising treatment
  setting
• Potential for better physical health care (44
  unmet needs)

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Pathways to Care Audit Data and GP Survey
NIMHE Primary Care Programme

• North Staffs Pathways to Care prospective audit
  n 45 (Macmillan, Ryles, Lee Shiers 1998/9)
• Sandwell GP interview n 3 (Alderton 2000 )
• Worcester Pathways to Care retrospective audit
  n 30 and GP workshop n 26 (Smith 2000)
• Walsall Pathways to Care review from case notes n
  18 (Rayne 2002)
• Gloucester GP Postal questionnaire n 15 (Davis
  2002)

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Who are they?
NIMHE Primary Care Programme

• 50 less than 24 and youngest aged 13
• Average age at onset 21
• 75 live with either parent(s) or spouse
• 29 have parenting roles
• 41 are employed or in full-time education

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What is the nature of their help seeking?
NIMHE Primary Care Programme

• Length of prodrome most commonly 2 6 m
• 54 seek help within 2 weeks of experiencing
  psychotic symptoms
• 18 32 of individuals seek help themselves
• 59 82 individuals lack insight, relying on
  family members to seek help on their behalf
• 17 say fear and stigma interfere with help
  seeking
• Typically it takes 3 5 contacts to achieve
  pathway to care
• Role of GP
• First point of professional contact 39 97
• Extremely helpful 37
• Fairly to not at all helpful 63

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Whos involved with the pathway (n 45)?
NIMHE Primary Care Programme
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What symptoms are presented?
NIMHE Primary Care Programme

• 7 show clear evidence of psychosis
• 82 are unclear
• 37 report purely physical / somatic symptoms
• 50 report emotional and psychological changes
• 25 report changes in work and social functioning

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How do GPs respond?
NIMHE Primary Care Programme

• Refer on
• 37 to a Consultant Psychiatrist
• 13 to Psychiatric Emergency Service
• 3 to Neurology
• 3 to Substance Misuse Services
• Initiate medication in 30 of cases

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Final Pathway to specialist services
NIMHE Primary Care Programme

• Duration of Untreated Psychosis 7 15m
• 50 received a prompt response to psychiatric
  symptoms
• 73 80 were hospitalised
• 36 59 required use of Mental Health Act
• 45 via police or criminal justice system
• 2 (n45) achieved effective engagement via
  the Psychiatric outpatient clinic

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What support is available to the GP from
specialist services?
NIMHE Primary Care Programme

• CAN USUALLY
• Contact Community Mental Health Teams for
  informal discussion of suspected FEP cases
• BUT IS NOT USUALLY PROVIDED WITH
• Local referral guidance for suspected FEP
• Access criteria for suspected FEP
• First episode prescribing guidance

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What does primary care need?
NIMHE Primary Care Programme
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Recognition and Referral
NIMHE Primary Care Programme

• GPs need
• higher suspicion through education and training
• Greater awareness about key alert indicators
• Greater sensitivity to carers concerns
• lower threshold Referral guidelines with
  explicit criteria which encourage prompt contact
  of specialist services about a possible FEP
• Practice based access to specialist liaison and
  advice to reduce stigma for client
• Greater awareness amongst general public

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Information and tools
NIMHE Primary Care Programme

• Help to know what is available and what to ask
  for
• Better awareness about self help groups and
• information materials for patients and
  carers
• Clearer advice about prescribing novel
  anti-psychotics
• and benzodiazepines
• Easy, quick and accurate assessment
  screening
• tools for use in Primary Care

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Primary Care Guidelines for Identification of
First Episode Psychosis Adapted from Launer
MacKean (2000)
12.4.02
12.4.02
EDIT
Sub-threshold/uncertain diagnosis
IMPACT
Clearly first episode psychosis
CMHT
If immediate risk
Crisis Team
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Liaison / Communication
NIMHE Primary Care Programme

• GPs need a working diagnosis (often not given)
  to assist in categorising and identifying ways of
  dealing with the problems
• Primary Care system improvement
• Primary care tagging notes/computerised records
  as with other high risk groups with annual
  recall/review
• Shared care protocols to develop GP role in
  monitoring and dealing with physical health
  problems, side effects, acute episodes and
  support to carers
• Overall whole system improvement
• To facilitate access, liaison, communication and
  contact and coordination of care across agencies
  (particularly the transition between CAMHS and
  Adult Services)

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How does primary care need to change?
NIMHE Primary Care Programme
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Improve access for young people and their families
NIMHE Primary Care Programme

• Whether dealing with major psychosis or a mild
  and self-limiting depression
• Greater ability to listen and act when families
  report concerns

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Primary Care Organisationsshould lead community
development
NIMHE Primary Care Programme

• Develop programmes of public education and
  specific education for teachers, youth workers as
  well as GPs about first episode psychosis
  (exemplified by TIPS Norway).
• Provide community-based initiatives that promote
  and encourage help seeking. (Indeed such an
  approach makes sense for all mental illness.)
• Promote mental health within the communities they
  represent to reduce the stigma of mental illness.
  

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In Summary
NIMHE Primary Care Programme
We believe Early Intervention needs more than
just Early Intervention Services But in
acknowledging the role of GPs within primary care
in these pathwayswe suggest..
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The real challenge lies beyond individual GP
competence and knowledge or raised GP awareness
of new EI services.
NIMHE Primary Care Programme
Primary Care becomes more accessible,
non-stigmatising and relevant to all young people
with mental illnesses. Young people with
emerging psychoses and their families should feel
confident that primary care and EI services will
integrate to provide the highly specialised
interventions they require in a timely fashion
both at the onset of the illness and in the
longer-term.