Post on 14-Aug-2015
A description of the Australian Early Psychosis Intervention Model and a proposal to establish a Pilot Early Psychosis Intervention Program in
Bolivia.
Dr. Guillermo Rivera, MD, MHPS, Dr. Guillermo Rivera, MD, MHPS,
PhD.PhD.
Victoria (Aus) Burden of Disease Study: Incident Years Lived with Disability rates per 1000 population by mental disorder
First Episode of Psychosis typically commences in young people: as do many of
the more serious mental disorders
Agenda
1. Early Intervention in psychosis: A paradigm of care for young people
2. The EPPIC Model
3. The Current State of Psychosis Treatment in Bolivia
4. Arguments for early intervention in Bolivia
5. Programme Overview
6. Sustainability
1. Early Intervention in Psychosis: A paradigm of care for young people
‘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:
1. Early detection of psychosis
2. Reduce the long duration of untreated psychosis
3. Importance of the first 3-5 years following onset (critical period) for later biological, psychological and social outcomes
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 follow-up and psychoed. during critical period
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
Assessmen
t Team
Optimizing 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
Intervening to Maximize Recovery & Prevent Relapse
Fun
ctio
ning
Age
Prodrome
2nd episode of psychosis
16 20 24
Assertive fo
llow-up
Community Team
First episode of psychosis
Implications of delayed treatment
Greater decrease in functioning
Loss of educational opportunities
Impaired psychosocial and vocational development
Personal suffering/family burdens
Potential poorer response once treatment is provided
Greater costs
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Jackson, H. J., & McGorry, P. D. (2009). The recognition and management of early psychosis: a preventive approach. Cambridge University Press.
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
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
The Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne has pioneered early intervention in Australia for young people with psychosis.
Courtesy Orygen Youth Research Centre
2. The EPPIC Model
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
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21
24
24
= Acute adult
= EPPIC beds
EPPIC serviceWestern Region of Melbourne (pop = 850,000)
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
Specified aims of EPPIC
The early identification and treatment of the primary
symptoms of psychotic illness. To improve access to, and reduce delays in, initial treatment To reduce the frequency and severity of relapses, and to increase
the time to a first relapse To reduce secondary morbidity in the post-psychotic phase of illness To reduce the disruption to social and vocational functioning and
psychosocial development in the critical period following the onset of
illness, when most disability tends to accrue To promote well-being among family members and reduce the
burden for carers
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EPPIC provides a clinical service for up to 2 years to young people aged 15- 24 years living in the catchment area who have been diagnosed with a first episode of psychosis.
EPPIC clinical work is provided in phases, according to the phase of illness. In a first episode of psychosis full recovery is possible with the appropriate multidisciplinary multi-faceted treatment. As treatment continues it needs to be tailored according to both the needs of the individual and their particular experience of the illness.
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Clinical Staging of Psychosis
3. The Current State of Psychosis Treatment in Bolivia
Less than half of the more than 250 adolescents and young adults* who are estimated to experience a first episode of psychosis in the city of Santa Cruz each year are ever diagnosed and receive psychiatric treatment.
Patients who are eventually recognized as having a first episode of psychosis are estimated to have experienced, on average, 2 years of symptomatology prior to diagnosis. At this stage, psychiatric treatment occurs most often in an inpatient setting and most frequently follows an episode of aggression that places the patient or others at risk for harm.
Most psychiatric treatment occurs in inpatient psychiatric hospitals during lengthy stays, which in Santa Cruz are not publicly funded. Outpatient options are limited.
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* Incidence estimate is based on World Health Organization incidence rates for schizophrenia spectrum diagnoses in
15-24 year olds.
Barriers
There is an especially strong stigma of mental illness throughout Bolivia.
Bolivia earmarked only 0.2% of its health budget for mental health. There aren’t public psychiatric facilities in Santa Cruz and all patients must pay out of pocket for a significant portion of their treatment
Bolivia has a especially low presence of psychiatrists, with an average of only 1 per 100,000 inhabitants
Informe de la Evaluación de Salud Mental en Bolivia Usando el Instrumento de la Evaluación de los Sistemas de Salud Mental de la OMS 2008.
Barriers 2
There is a lack of mental health training for primary care health personnel. Limited ability to appropriately screen for, identify, and treat mental illnesses in the general population.
Bolivia has a highly fragmented medical system.
There are no electronic medical records. There is limited coordination of care between individual providers as well as between group providers, such as clinics and hospitals.
Informe de la Evaluación de Salud Mental en Bolivia Usando el Instrumento de la Evaluación de los Sistemas de Salud Mental de la OMS 2008.
4. Arguments for early intervention in Bolivia
It does not require significant investment in medical or physical infrastructure, technology or high-cost, hard-to-obtain medications.
It does not rely heavily on psychiatrists, of whom the supply is limited in Bolivia, or on a large workforce of highly trained personnel.
On a per patient basis, early intervention is far less costly than inpatient crisis treatment, which is the current de facto standard of psychiatric care for psychosis in this country.
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4. Arguments for early intervention in Bolivia
Our proposed early psychosis intervention program represents a low-tech, appropriate and potentially very transferable technology.
Bolivia does simply not need more mental health care – it needs a shift towards smarter, more strategically organized, more economical care – and this programme would represent an important step in this direction.
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5. Programme Overview
A pilot early psychosis intervention program called
Programa de Apoyo y Rehabilitación de la Sicosis
(PARES) will provide age appropriate bio-psycho
social treatment and support for 15-25 years old
with first episode psychosis and their families,
who reside in the neighborhood of Plan 3000 in the
city of Santa Cruz de la Sierra, representing a
catchment area of 350,000.
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Incidence data
Population of Plan 3000 350000% between 15-25 yo 25%Population growth rate 5%Incidence of new cases of affective and nonaffective psychoses 0,001Number of new cases per year 88% detected and referred year 1 25%% detected and referred year 2 33%# of new clients year 1 22# of new clients year 2 30Total clients at end of year 2 52
PARES Aims
This program’s specific objectives are to: Improve short and long-term outcomes for those
with psychosis Increase speed of recovery Decrease the need for hospitalization Reduce family disruption Decrease rates of relapse
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Four Principal Components
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Attention and Treatment
Service Model
Our programme will be implemented under a
"radial" model basis, where primary care,
responsibility and focus care program is in the
hands of current and leading providers of mental
health services (the "spokes"), but the contribution
of specialists is provided by a treatment team of
experts dedicated to first episode (the "hub").
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The team
manager
Full-time position The centralized ‘Hub’
provides support for the
spoke workers through
the delivery of clinical
supervision, training,
administration and
management.
Administrator Full-time position
Consultant
Psychiatrist
Part-time position
Consultant
Psychologist
Part-time position
The Hub
Social Worker Full-time position The community location
of the ‘Spokes’, provides
excellent opportunity to
encourage referrals from
local primary, voluntary
and generic youth
services, thus reducing
the DUP.
Mental Health
Nurse
Part-time position
Assistant
Psychologist
Part-time position
Assistant
Psychologist
Part-time position
The Spokes
6. Sustainability
We do believe that public funding for mental illness will increase over time, but it will take a significant, concerted, well organized, and consistent lobbying effort in order to make this change happen.
We have already begun working with and providing support to the organization of family members of people with psychosis in the city of Santa Cruz. We will continue to work with this organization, training and providing support in order to optimize their lobbying efforts.
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What is currently most lacking in order to support any lobbying effort for improved mental health treatment in Santa Cruz is a programme such as we are proposing that would provide a model of what mental health treatment should actually look like.
Anyone with psychosis, should have a right to expect the kind of comprehensive bio-psycho-social treatment that our program proposes. This is the argument that we believe we will be able to effectively make and communicate towards the public and lawmakers over time.
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Using terms often applied to sustainable development, early psychosis intervention programs represent an appropriate and potentially very transferable technology.
Therefore, one of the principal goals of our programme will be to create a model or blueprint that might be replicated in similar communities across Bolivia beyond Santa Cruz and possibly in other developing countries.
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Summary
This program includes an innovative outreach program that combines sound business principals with social goals in order to specifically target the largest barrier to early psychosis treatment in Bolivia: the stigma of mental illness.
By utilizing a mobile, multidisciplinary treatment team that emphasizes the roles of trained case managers focused on providing intensive individual and family support in the home, this program will provide culturally appropriate care that will leverage contributions from a limited supply of psychiatrists and shift dependence away from a fragmented medical system.
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