Earlier intervention in psychosis everybodys business

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Earlier intervention in psychosis -
everybodys business

A primary care view
Dr David Shiers Dr Jo Smith Joint leads
NIMHE National EI Programme
Haugesund. Workshop on primary care. Sept 2nd
2008
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Learning objectives

• Explore the interface between psychiatry and
  primary care
• Develop a marketing strategy to sell early
  intervention to primary care colleagues

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• Average GP (list 1800) sees each yr
• 250 new mental health cases
• 5 with severe mental health problems
• 1 with a first episode of psychosis

• At any one time is responsible for
• 10-20 registered on his/her list with psychosis
• 30-50 without any support from specialist care
  (Kendrick,2000)

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• Context
• Knowledge of individual before onset of psychosis
• Family practice

• Continuity
• Alertness to changes in behaviour and functioning
  which may precede first episode and relapse
• Potential for better physical health care
• Care setting
• More accessible and less stigmatising

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• Some GP views
• I know that I cannot look after people with
  severe and enduring mental health problems. I do
  not have the skills or the knowledge. I couldn't
  do it well"
• Sometimes they have to be standing on a bridge
  before we can get people help and we have to
  exaggerate symptoms to get the psychiatrists
  attention at an earlier stage
• Helen Lester BMJ 2005

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• Contrasting with patients views typified by
• "I mean, the GP has to have some understanding
  of mental health but I don't expect my GP to know
  all of the issues to do with my illness...
• ...I would though expect him or her to refer me
  to a specialist person. The important thing is
  that somebody is looking after you so it's not
  just you on your own.
• Helen Lester BMJ 2005

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GPs see a FEP at an age when other serious
mental disorders tend to develop
Victoria (Aus) Burden of Disease Study Incident
Years Lived with Disability rates per 1000
population by mental disorder
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Pathways to Care Audit Data and GP Survey

• North Staffs Pathways to Care prospective audit n
  45 (Macmillan, Ryles, Shiers Lee 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?

• 50 lt 24 youngest aged 13
• Average age at onset 21
• 75 live with parent(s) or spouse
• 41 are employed or in full-time education

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Pathway players (n 45)
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Symptoms presented to GPs?

• 7 - clear evidence of psychosis
• 37 - physical / somatic symptoms
• 50 report emotional and psychological changes
• 25 report changes in work and social functioning

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Nature of their help-seeking to GP?

• Prodrome typically 2 6 m
• 50 seek help lt2 wks of psychotic symptoms
• 20 of individuals have courage to seek help
  themselves
• 75 relied on family members to seek help on
  their behalf
• 5 contacts on average to achieve pathway to care
• GPs are first point of professional contact
  65

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DANGER AHEAD!!!Pressure wave- trapped

• 7-15m treatment delays
• Families concerns ignored
• Crisis response is the rule
• 7380 hospitalised
• 3659 Mental Health Act
• 45 police involved
• Lifetime suicide risk 10
• 2/3 within first 5yrs
• around the FEP
• 50 disengage likely crisis reengagement

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Some get marooned
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 a ghetto of disability
• Relapse and remission
• Path to social exclusion and health inequality?

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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... a path to inequality

• Excluded
• 12 with a job
• In previous 2 weeks (Nithsdale survey)
• 39 either had no friends or had met none
• 34 had not gone out socially
• 50 no interest or hobby other than TV
• one in four have serious rent arrears
• 3x divorce rate
• Dis-ease ? up to 25 years less life
• 33 suicide and injury
• 66 premature deaths from physical disorders
• Eg. Deaths due to coronary heart disease kills
  more than two-thirds of people with
  schizophrenia, compared with about a half in the
  general population,
• Accounted for by excess smoking obesity
  hypertension diabetes
• Antipsychotics link with obesity, diabetes (up
  to 5x rate)

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Thats the problem we are trying to solve
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What do young people and families need?

• Optimism
• Confidence in a whole systems response to their
  help-seeking
• Earlier detection
• of psychosis
• of at risk mental state?
• Specialist services that
• do psychosis as well as do young people
• pre-empt crisis offer less traumatic first
  engagements
• offer age / phase specific care in critical
  period of first 3-5 yrs
• provide recovery oriented services from the start
• Support for families

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What do specialist services need from primary
care?

• GPs as key pathway players to
• Listen for and act on family concerns
• Be aware of key indicators
• Be flexible and accessible to promote
  help-seeking of these young people
• Involve EIS at the earliest opportunity
• Organise care to meet physical health need

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What does primary care need from specialist
services?

• Youth friendly approach ban outpatient clinics!
• Low threshold of access to specialist advice
• MH assessment of those with suspected FEP
• Monitoring / review of those deemed at high
  risk of FEP
• Individual support for FEP
• Collaborative approach
• Clear pathways (e.g. for those aged 14-18 for
  those with co-morbid drug misuse)
• Relapse planning
• Planned exit from EIS

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Marketing EI to primary care?
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Colins journey
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Rapids
PC
Eddy
Family crisis
Distressed
Isolated from friends
Family
Drop out of Educn
Youth worker
Suicide attempt
Mental illness
Rapids
Offending behaviour
Drugs
No job
Homeless
Rapids
No money
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Using Nature EddiesEarly detection of danger
ahead

• Pull ashore, get out, take a look and regroup
• Use understanding of the nature of the journey
  and knowledge to stop and even regain some ground

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Family
Eddy
Guides
White water
Rapids
Lookout with life ring
Safety raft
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Supporting GPs to do a difficult job better
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• Early intervention is everybodys business
• EI services insufficient by themselves
• GPs offer continuity, context and family
  practice
• Key role in care pathway of those with emerging
  psychosis
• Ability to listen and act on concerns of the
  family
• In it for the long term
• EI for bodies as well as minds

Equipped for the life ahead both for the young
person and their family
Acknowledgements to Dr. Roy Morris Dunedin and
Dr Maryanne Freer, Newcastle for contributing the
white water rafting metaphor and to Guzer.com
for the images
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Thank you
david.shiers_at_csip.org.uk joda_at_lineone.net www.ear
lydetection.csip.org.uk