early intervention: the international perspective early intervention: the international perspective...
TRANSCRIPT
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Early Intervention:Early Intervention:The International PerspectiveThe International Perspective
Paddy Power
“A Stitch in Time Saves Nine”
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Development of Early Psychosis Programs
Melbourne, mid-80’s Buckinghamshire, mid-80’sNorth Birmingham UK early 90’sGermany, 1990’s (research1970’s) USA & Canada, early 90’s Scandinavia, mid-90sSwitzerland mid - 90sAmsterdam, late 90’sAustralia late 90’sUK 1999/2000Far East & South East Asia, 2001
Networks: IEPA & European FE Schizophrenia Network
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Types of Early Intervention Model
• Option 1: Basis? (CAMHS, Adult, 1° Care, Youth service)
• Option 2: Service model? (Specialist vs generic)
– Specialist EI services• Stand alone EI service• Hub and Spoke model• Piggy-back supplementary EI model• Tertiary consultation EI services/clinic
– Generic Based Services• Top up with embedded EI worker/s• Top up with EI training and clinical guidelines
– Research based interventions
• Option 3: Degree of community integration – Public health promotion campaigns– integration with social services, education, employment, housing, A&D services, service user
agencies
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Aims of an Early Intervention service
• Reduce delays (& DUP) by:– promoting early detection and
collaborative engagement in the community
• Optimise assessment & diagnosis by:– Comprehensive Bio/psycho/social assessment
• Maximise recovery by: – providing integrated bio/psycho/social community Rx – focus on functional as well as symptomatic factors– addressing co-morbidity and treatment resistance early
• Prevent relapse by:– ensuring assertive followup and psychoed. during critical period
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Intervening to Maximise Recovery & Prevent Relapse
Fun
ctio
ning
Age
Prodrome
2nd episode of psychosis
16 20 24
Asserti
ve follo
w-up
Community Team
First episode of psychosis
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Optimising Inpatient Care and Treatment in Early Psychosis?
Fun
ctio
ning
Age
Prodrome
2nd episode of psychosis
16 20 24
First episode of psychosis
FEP Inpatientservices
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Intervening to reduce the Duration of Untreated Psychosis (DUP)
Fun
ctio
ning
Age
Prodrome
2nd episode of psychosis
16
First episode of psychosis
20 24
Early
detection &
Crisis
Assessment
Team
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Intervening in the Prodrome Phase of Early Psychosis
Fun
ctio
ning
Age
Prodrome
First episode of psychosis 2nd episode
of psychosis
16 20 24
Prodrome
clinic
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Configuration of LEO Service
Primary Care
Early detection & crisis assessment team
LEO Community
Team
LEO Inpatient
Unit
2 ye
ar f
ollo
w-u
p
Prodrome clinic
LEO-CAT OASIS
psychotic prodromal
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Canada’s Early Intervention Services
Ontario:•PEPP, London •FEPP, Toronto •Psychotic Disorders U., Hamilton•Ottawa FEPP•KPP&TP, Kingston
Alberta:•EPT&PP, Calgary (930,000)
British Columbia:•EP Initiative of British Columbia•EPIVMHC,Victoria•Vancouver•EPIP, White Rock
Quebec:•Levis•Montreal•Quebec City
Nova Scotia:•NSEPP•Halifax -
Saskatchewan:•EIPP, Saskatoon
Key figures:•Jean Addington•Bob Zipursky•Ashok Malla•Lili Kopala
Newfoundland•N&L EPP
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Early Psychosis Programs in the USA
Pittsburg:•EI program (Keshevan)
N. Carolina:•FEP & prodrome studies (Lieberman)
New York:•Prodrome (Cornblatt)
Yale, New Haven:•PRIMHE (T. McGlashan)
Portland, Maine•PIER service (McFarlane)
LA California:•UCLA (Ventura, Neuchterlien etc)
Bethseda, MD: •NIMH research:(Wyatt etc)
Salem, Oregon:•Early Assessment & Support Team (EAST) (pop 600,000) Managed care funded
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New Zealand’s Early Intervention Services
• Auckland: EPI Centre, Kari Centre, Taylor Centre, Manaaki CMHT - FEP, St Lukes FEP, Hartford House EPI, Campbell team Lodge EI team
•Wellington: Wellington EI service (400,000)
•Christchurch: Tatara House EIP service (380,000)
•Dunedin: Aspiring House EI service (150,000)
..
...
New Zealand National Early Intervention Group
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Early Psychosis Programs in Australia
Victoria:•EPPIC•Dandenong•EP Program, Alfred Hosp.•Central East EP Project
Western Australia:•First Psychosis Liaison Unit, Bentley•EPOES, Fremantle •EEPP, Rockingham/Kwinana
New South Wales:•YPPI service, Gosford•EP program, Marouba•EP program, North Sydney•EPIP-SWAHS, Liverpool•EPIC, Penrith•Western Sydney FEPP
South Australia:•Noarlunga EP Program
Queensland:•Uni of Brisbane studies
ACT:•Canberra EI service .. . ..
.
..
National Early Psychosis Project (based at EPPIC)
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South west Area
4 sectors•Inner West: (145,000)•North West: (266,700)•Mid west: (208,000)•South West: (237,600)
(Each sector has 20 CCU beds for long-stay patients)
EPPIC16 21
21
24
24
= Acute adult
= EPPIC beds
EPPIC serviceWestern Region of Melbourne (pop = 850,000)
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Overview of Mental Health Services For Kids & Youth
Older Adolescent Service(follow-up to age 19)
EPPIC(18 month follow-up)
Youth Assessment Team
AcuteInpatient
Care
DayGroup
Program
Familywork
IntensiveOutreachSupport
Outpatient Case
Management
Western Region of Melbourne (800,000)
Non-psychotic Ages 15 -19
PsychoticAges 15-30
CognitiveTherapies
PACEClinic
Prodrome
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PACE Treatment Trial(Phillips et al 2000, McGorry et al, 2002)
(n= 59)
0%
5%
10%
15%
20%
25%
30%
35%
40%
after 6 monthstreatment
NSI
Risp. +CBT
• RCT of CBT + low dose Risperidone X 6/12 versus supportive psychosocial therapy (NSI)
• Both groups ~ 50% received SSRIs
• Those fully compliant with Risperidone afforded greatest protection at 6 months (5.6%) and follow-up after meds ceased
• 2 suicides in refusal group (n=33)
Transition Rate to Psychosis
35.7%
9.7%
P = 0.026 Fisher Exact test
(N=28)
(N=31)
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South East Asian Early Psychosis Network
Singapore:EPIP
1 team covers 4 M(S. Chong et al)
Tokyo, Osaka
(South Africa)Palau, Miconesia
Hong Kong: EASY - 4 teams cover 7M
(Eric Chen et al)
South Korea
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Swiss Early Psychosis Programs
Geneva & Zurich:Swiss Early Psychosis Project SWEPP (Simon, Umbricht & Merlo)
Bern:•Uni Hosp. of Social & Comm. Psych.(Gekle) (Merlo - moved to Geneva)
Basil:•Uni Hosp. Basil: Basil FEPSY screening study (Gschwandtner et al)
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German Early Psychosis Programs
Mannheim:•Central Insitute of Mental Health (Hafner, Maurer et al)
Dusseldorf:•RCT of psychological Rx in FEP (Klinberg)
Bonn:•Prodrome Rx (Hambrecht et al)
Cologne:•Cologne early Recognition study (Klosterkotter, Schultze-lutter et al)
Heidelberg: •Heidelberg Early Adolescent & Adult Recognition & Therapy Centre for Psychosis (HEART) EI service since since 1994 (Franz Resch et al)
Vienna, Austria:•Adolescent EI program at University Hosp. of Vienna (Amminger, Edwards)
......
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Scandinavian Early Psychosis Services
0
2
4
6
8
10
12
14
16
DUP (median in weeks)
Early detectionStandard
Norwegian Services:•TIPS - Roskilde/Stravanger (Larsen, Johannessen etc)•UNA-projektet, Oslo•EOP, Skien
Swedish Services:•Parachute Project (1.5 M), Stockholm•Sodertalja Psykiatriska Sektor, Sodetalje•TUPP Project, Stockholm (Cleland)
Finland:•Turku: Detection of early Psychosis project(Suomela et al)
Control
DU
P m
edia
n (
wee
ks)
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OPUS study(Nordentoft et al )
RCT of Assertive Community Follow-up in First Episode Psychosis
0%
5%
10%
15%
20%
25%
30%
35%
Psychotic Sx 2years
-ve Sx 2 years
Standard teamsEarly Intervention team
% c
ases
with
mod
/sev
ere
sym
ptom
s
Merete Nordentoft, Bispebjerg Hospital, Department of Psychiatry, 2004
The cost saved for in-patient care/year = €600,000 for 100 patients = wages of 10 staff
0
10
20
30
40
50
60
70
80
90
Bed days in 1st year
Standard teams
Early Intervention team
582 patients (18 - 45 year olds) with non affective first episode psychosis
Mea
n B
ed d
ays/
patie
nt
(p <0.05)
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Dutch & Belgian EI Programs
Belgian Projects:•PECC (Janssen-Cilag)
Netherlands:•Academic Medical Centre (Don Linszen)•University of Maastricht: NEMESIS (Van Os, J.) •University Med Centre, Utrecht (Dutch Prediction of Psychosis Study- DUPS)
Other European Projects:•European Prediction of Psychosis (EPOS) study (6 centres: Birmingham, Amsterdam, Cologne, Turku, Santander, Dannstadt)•Dublin: SJOG Hospital (E. O’Callaghan)•Bordeaux: (Helen Verdoux)•Barcelona, Madrid, Santander: 4 prodrome research programs•Lisbon: planning EI service•Eastern European, Russian & Middle East: research programs & plans for services
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Early Intervention Services in England
EI teams include:•North Birmingham EI service•LEO & OASIS service•Plymouth service•Manchester •Tower Hamlets•ETHOS•COAST•Sheffield EI service•STEPS, Poole
•NHS plan: PIG
•IRIS: Newcastle declaration
•50 teams by 2005-23 EI teams to date
£1M
Glasgow: •EI service (A Blair)
Edinburgh•YPU @ Royal Edinburgh Hosp.•Edinburgh High Risk study(E. Johnstone)
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RCT of LEO Community Team Engagement with Services at 18 months
(N=138)
In contactwith services
In hospital Lost tocontact
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
LEOControl
p<0.02
At 6 months:
African Caribbean engagement:
= 89% vs 27 %:
LEO vs Control
% C
lien
ts s
till
att
end
ing
at 1
8 m
onth
s
(Craig et al, 2004)
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Adherence to prescribed antipsychotic medication over 6 months
1
0.5 0.61
0.28
1 2 3 4 5 6Months post randomisation
0
Pro
port
ion
taki
ng m
edic
atio
n
LEO
OTHER
(Craig et al, 2004)
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LEO Trial ResultsRelapse at 18 months, from full or partial recovery
(N=122)
p<0.05
% o
f cl
ient
s w
ho r
elap
sed
(Craig, Garety et al, 2004)
Significant better improvements @ 18 months follow-up::
• Positive and Negative symptoms
• Insight & treatment adherence
• GAF score
• Satisfaction with services0%
10%
20%
30%
40%
50% LEOControl
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Hospitalisation rates for LEO patients
0%10%20%30%40%50%60%70%80%90%
100%
% LEO patients admitted
Control Group
LEO Trial Rx. group
Inter trials group
1st LEO CAT group
LEOCAT trial
(n=71)
(n=63)
(n=156)
LE
O T
rial
Gro
up
1st
LE
OC
AT
% L
EO
pat
ien t
s ad
mit
ted
2000 - 2001 - 2003 - 2004-2005
LEO Ward opens
LE
OC
AT
Tri
al
Inte
r st
udy
LE
O g
roup
Con
trol
gro
up
(st
and
ard
car
e)(n=73)
(n=73)
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Discharges Destinations after 2 years Follow-up with LEO
Lost10%
GP39%
CMHT32%
Died1%
OPD12%
Private 3%
Prison2%
Rehab1%
136 LEO clients discharged to date:
• 37 to Out of Area services
– 17 overseas
(n=269)
20 additional clients overdue discharge
–14 waiting CMHT transfer
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Economic Benefits of Intervening Early:Comparison of LEO vs. Estimate of Standard Costs
in First Episode Psychosis(2003 figures)
£18,527
£8,951
£8,323
£7,033
£-
£5,000
£10,000
£15,000
£20,000
£25,000
Standard NHSservices
LEO service
CMHT's costs
Hospital costs
* Based on ratios from Agustench & Cabases (2000), estimates by Guest & Cookson (1999) and adjusting for 3% inflation for 2003
LEO costs (including LEOCAT):
Total of £15,985 over 2 years
NH
S C
ost p
er f
irst
epi
sode
pat
ient
/yea
r
Total standard NHS cost (estimate)
Total = £26,851 over 2 years
Savings with LEO = £10,866 (40.4% less than standard NHS costs)