Early Intervention:Early Intervention:The International PerspectiveThe International Perspective

Paddy Power

“A Stitch in Time Saves Nine”

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

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

                 

     

Gallery Image 34 of 191

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

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

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

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

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

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

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

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

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

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)

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)

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

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)

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

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)

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)

......

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)

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)

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

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)

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)

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)

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

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)

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

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)