Early intervention service for psychosis: views from primary care

Aim: Although General Practitioners (GPs) have a pivotal role in early detection and treatment of psychosis, there is sparse information on their views of early intervention (EI) services and how information related to EI should be delivered. Method: Since inception, DETECT (Dublin East Treatment and Early Care Team), Ireland's pilot EI project, mailed information packs and provided information through the local GP continuing medical education (CME) network. After 1 year, we surveyed GPs within DETECT's catchment area for their views on the service being provided. Results: One hundred and twenty‐six (36%) responded and 80% found the EI service very/extremely useful. GPs reported that the combination of CME session and information packs were more useful than information packs alone. Those who attended CME meetings were significantly more likely to refer suspected cases (P < 0.01) and more likely to find the service useful (P < 0.001). Conclusion: The EI service for psychosis is well‐received among GPs. Information about EI delivered through CME appears to have a greater impact on referral rates and satisfaction levels than mailed information.     

An early intervention for psychosis service as compared with treatment as usual for first psychotic episodes in a standard community mental health team. Basic concepts and the service

Early intervention in psychotic illness is a key area of development in community mental health. In this first of a series of articles the basic concepts of early intervention in psychosis are described, as is the present policy of the UK government for developing early intervention services throughout England. The development of an early intervention service in Luton, Bedfordshire is then described. Subsequent articles will describe the three year outcomes of this service, compared with treatment as usual in a community mental health team.     

Mental health care for young people: early intervention in psychosis

During the last 15 years, much progress in early interventions (Els) focusing on psychosis in the young people has been made, and new revelations about psychotic disorder including schizophrenia have come out. Furthermore, findings from clinical epidemiology in the general population and clinical genetics of psychiatric diseases have revealed the "trajectories" before the onset of psychosis. Current state and challenge of Els in the first-episode psychosis (FEP) and high risk state (HRS) (putatively prodromal state) for psychosis will be selectively overviewed in this article. Although Els in FEP shorten the duration of untreated psychosis and improve the short-term outcome, it would be required to sustain the EL effects for a long time. Els in HRS also prove fruitful, but predictor of transition to psychosis must be established for the clinical practice. Furthermore, Els in the earlier HRS targeting at the cognitive dysfunction and negative rather than positive symptoms under ethical consideration will improve psychosocial impairments. Clinical staging concept using in general medicine for the serious physical diseases might enable an individualized medicine in psychiatric EIs.     

Three year outcomes of an early intervention for psychosis service as compared with treatment as usual for first psychotic episodes in a standard community mental health team. Preliminary results

Forty patients who had been treated for three years in an ad-hoc, assertive treatment team for patients who had suffered a first psychotic episode were compared to forty patients who had been followed up after a first psychotic episode in a community mental health team. All patients had suffered a first or early psychotic episode. The main differences between the two teams was that the ad-hoc team was assertive in its approach, offered more structured psycho-education, relapse prevention and psycho-social interventions, and had a policy of using atypical anti-psychotics at the lowest effective dose. There were many differences in outcome measures at the end of three years between the two groups. The EI patients are more likely to be taking medication at the end of three years. They are more compliant with medication. They are more likely to be prescribed atypical medication. The EI patients are more likely to have returned to work or education. The EI patients are more likely to remain living with their families. They are less likely to suffer depression to the extent of requiring anti-depressants. They appear to commit less suicide attempts. The patients in the EI service also appear to be less likely to suffer relapse and re-hospitalisation, and are less likely to have involuntary admission to hospital. They have systematic relapse prevention plans based on early warning signs. They and their families receive more psycho-education. These indications suggest that the EI patients are at the end of three years better able to manage their illness/vulnerability on their own than the CMHT patients. More patients in the EI group stopped using illicit drugs than in the CMHT group. All the above changes were statistically significant except for the number of patients who stopped using illicit drugs. In this case it is believed that the sample size was too small to demonstrate significance. These results suggest that an ad-hoc early intervention team is more effective than standard community mental health team in treating psychotic illness.     

The effect of diagnosis and age on the DST: a metaanalytic approach

The authors present new data on the results of the pretreatment Dexamethasone Suppression Test (DST) in 164 drug-free inpatients, as well as on the effects of age on postdexamethasone cortisol values. Nonsuppression rates were 18% in schizophrenic patients (n = 44), versus 46% in patients with a major depression (n = 56). In addition, a significant correlation was found between age and the 4:00 PM postdexamethasone cortisol value among the depressed patients (r = 0.33). The authors then applied a metaanalysis to summarize 25 other studies that have addressed the schizophrenia/major depression dichotomy as it relates to the DST outcome. Nonsuppression rates were consistently different in schizophrenic patients (19%) when compared to patients with a major depression (51%) or normal controls (7%). These differences were highly significant as measured by the Mantel-Haenszel chi-square statistic. A metaanalysis applied to a series of correlations obtained from 14 other studies reporting an age/postdexamethasone cortisol relationship in affective patients indicated a modest, but significant correlation (r = 0.24) in a total of 1284 patients (p less than 1 x 10(-8)).     

One-year outcome of low-intensity booster sessions versus care as usual in psychosis patients after a short-term psychoeducational intervention.

OBJECTIVE: In this study we aimed to evaluate long-term effects of a community-based, quality of life oriented psychoeducational intervention for schizophrenia with and without booster sessions. METHOD: One hundred and three outpatients with a diagnosis of schizophrenia or schizoaffective disorder completed a 9-week psychoeducational programme. At the end of the programme groups were block-randomised to either an extension programme comprising monthly booster sessions for a further nine months (booster condition) or routine clinical care with no further group meetings (non-booster condition). Outcome measures were applied before and after the seminar and at 6 and 12 months. RESULTS: Positive effects were observed after the short-term 9-week programme with regard to symptoms, knowledge about the illness, illness concept, control convictions and quality of life. These effects were retained over the 12-month period in both conditions. The only relevant difference between the booster and the non-booster conditions concerned external control convictions. CONCLUSION: Overall this 9-week programme has shown encouraging effects still present at 12 months after baseline independent of booster or non-booster conditions. Further studies are needed to explore whether a subgroup of patients, those with impaired neurocognitive and social functioning, can benefit significantly from booster sessions.     

Identification of patients with recent-onset psychosis in KwaZulu Natal,South Africa: a pilot study with traditional health practitioners and diagnostic instruments

Social Psychiatry and Psychiatric Epidemiology - There is considerable variation in epidemiology and clinical course of psychotic disorders across social and geographical contexts. To date, very...     

Three year outcomes of an early intervention for psychosis service as compared with treatment as usual for first psychotic episodes in a standard community mental health team - final results

Sixty-two patients who had been treated for three years in an ad-hoc, assertive treatment team for patients who had suffered a first psychotic episode were compared to sixty-two patients who had been followed up after a first psychotic episode in a community mental health team. All patients had suffered a first or early psychotic episode. The main differences between the two teams was that the ad-hoc team was assertive in its approach, offered more structured psycho-education, relapse prevention and psycho-social interventions, and had a policy of using atypical anti-psychotics at the lowest effective dose. There were many differences in outcome measures at the end of three years between the two groups. The EI patients are more likely to be taking medication at the end of three years. They are more compliant with medication. They are more likely to be prescribed Atypical Medication. The EI patients are more likely to have returned to Work or Education. The EI patients are more likely to remain living with their families. They are less likely to suffer depression to the extent of requiring anti-depressants. They appear to commit less suicide attempts. The patients in the EI service also appear to be less likely to suffer relapse and re-hospitalisation, and are less likely to have involuntary admission to hospital. They have systematic relapse prevention plans based on Early Warning Signs. They and their families receive more psycho-education. These indications suggest that the EI patients are at the end of three years better able to manage their illness/vulnerability on their own than the CMHT patients. More patients in the EI group stopped using illicit drugs than in the CMHT group. All the above changes were statistically significant except for the total improvement in employment status and education status, which however approached significance. These results suggest that an ad-hoc Early Intervention Team is more effective than standard Community Mental Health Team in treating psychotic illness.     

Predictors of subjective recovery from recent-onset psychosis in a developing country: a mixed-methods study

Purpose

This study was conducted to: (a) investigate the levels and progress of subjective recovery from recent-onset psychosis; (b) examine its predictive factors and; (c) describe perceived challenges and opportunities affecting recovery. The findings were expected to help inform recovery-oriented psychiatric care in low-income, particularly African, countries.

Methods

This sequential explanatory mixed-methods study involved 263 service users with recent-onset psychosis from Northwestern Ethiopia. For the quantitative part, a 9-month longitudinal study approach was employed with three time point measurements over 9 months. Predictor variables for subjective recovery from recent-onset psychosis were identified by hierarchical multiple linear regression tests. Following the quantitative survey, individual qualitative interviews were conducted with 19 participants. Interview data were transcribed and thematically analysed.

Results

High mean subjective recovery scores were recorded throughout the study (Questionnaire about the Process of Recovery score ranging from 44.17 to 44.65). Quality of life, internalized stigma, disability, hopelessness, satisfaction with social support, and central obesity were significant predictors of subjective recovery across the three time points. Participants’ perceived challenges and opportunities affecting their recovery were categorized into four themes.

Conclusion

In Ethiopia, a low percentage of individuals with SMIs initiate psychiatric treatment and many discontinue this to attend spiritual healing. In this study, the Ethiopian SMI patients engaged consistently in psychiatric treatment indicated high mean subjective recovery scores. Devising mechanisms to integrate the psychiatric treatment and spiritual healing sectors are suggested. Approaches to improve quality of life, functioning, hope, internalized stigma and provide need-based social support are suggested.

     

Specialty care for patients with epilepsy must become standard of care

Epilepsy is a complex, common disorder with severe consequences for patients. The authors believe that a significant percentage of patients are receiving suboptimal care. The national standard of care needs to be upgraded to include the notion that patients with less than total seizure control or those suffering from any medication side-effects should be given the opportunity to receive specialty care by physicians with specific expertise in the field of epilepsy.     

Cost-effectiveness of memantine compared with standard care in moderate-to-severe Alzheimer disease in Canada.

OBJECTIVE: To conduct a cost-effectiveness analysis comparing the addition of memantine to standard care (that is, without acetylcholinesterase inhibitors) with standard care alone in moderate-to-severe Alzheimer disease (AD) in Canada. METHODS: A 2-year Markov model estimated clinical effects in terms of quality-adjusted life years (QALYs) and time in complete dependence as well as societal costs in four 6-month cycles. Health states were defined by AD severity assessed with the Mini-Mental State Examination (moderate = 10 to 19; severe < 10), by level of dependence in activities of daily living, and by death. Transition probabilities were estimated by combining data of patients with moderate-to-severe AD from all relevant clinical trials. QALYs were estimated from a UK epidemiologic study. The initial distribution and use of medical and support services for each health state was obtained from the Canadian Study on Health and Aging with current estimates of frequency of use and unit prices applied. RESULTS: Compared with standard care, the memantine strategy saved more than 1 month of complete dependence and produced 0.03 additional QALYs, with no additional cost. Probabilistic sensitivity analyses give an 83.3% chance that memantine treatment is cost-neutral, an 89.5% chance of its being cost-effective if the decision maker is willing to pay $20 000 for a QALY, and a 96.2% chance with a willingness to pay $100 000 per QALY. Robustness of results was confirmed through 1-way and scenario-based sensitivity analyses. CONCLUSIONS: Our evaluation found that memantine monotherapy produced relevant health benefit, compared with standard care alone, with no additional costs. Results are consistent with other economic evaluations of memantine conducted in Europe and the United States.     

Filling the implementation gap: a community-academic partnership approach to early intervention in psychosis

Aim: The aim of this study was to describe the development of a sustainable community early psychosis programme created through an academic–community partnership in the United States to other parties interested in implementing early psychosis services founded upon evidence‐based practices within community settings. Methods: The service was developed around a sustainable core of key components, founded upon evidence‐based practice, with additional flexible elements that could be adapted to the needs of the individual commissioning county. This paper describes the ways in which funding was sourced and secured as well as the partnerships developed through this process. Results: Successful development of the Prevention and Recovery from Early Psychosis (PREP) programme in San Francisco County, California. PREP clinicians have received extensive training in the evidence‐based approaches that are available through the programme and treated 30 clients and their families in the first year of operation. Conclusions: Development of a sustainable community programme of this type in a non‐universal health‐care setting, which is historically seen as non‐integrated, required extensive partnering with agencies familiar with local resources. Implementation of the community–academic partnership bridged the gap between research and practice with successful integration of fidelity practice at the community level. The community partners were effective in sourcing funding and allocating resources, while the academic side of the partnership provided training in evidence‐based models and oversight of clinical implementation of the model. Stringent evaluation of the impact of the service is our next focus.     

Integrating primary care and early intervention in psychosis services: a general practitioner perspective

Aims: Earlier detection and treatment of psychosis is associated with improved health outcomes. While the role of specialist services to facilitate early diagnosis and treatment has been extensively described internationally, little data on their impact on general practice has been reported. A new specialist service for psychosis – the ‘Dublin East Treatment and Early Care Team (DETECT)’– has recently been established. This study aimed to describe general practitioners' (GPs) attitudes towards working within the catchment area of an early intervention service. Methods: A purposive sample of GPs practising in DETECT's catchment area was identified from the Irish Medical Directory and invited to participate in a semi‐structured interview. The sampling parameters were solo/practice and area of practice. Participants were provided with information regarding the new service and a range of educational material. Each interview was reviewed by two researchers who identified dominant themes. The study was approved by the Research Ethics Committee of the Irish College of GPs. Results: 16 GPs were interviewed. The DETECT early intervention model was identified as reducing the challenges of managing psychosis in primary care including the practical difficulties of accessing psychiatric assessment and the pervasive effect of stigma. Participants viewed communication between primary and specialist care as essential to the success of early intervention services. Conclusions: General Practice has an important role in early detection of psychosis and accessing timely psychiatric evaluations of suspected psychosis. Increasing awareness among GPs and ensuring the early intervention model is responsive to primary care can support this role.     

Depression care for people with cancer: a collaborative care intervention

Depression management for patients with chronic medical illnesses, including cancer, is often inadequate. “Depression Care for People with Cancer” (DCPC) has been designed to be integrated into specialist cancer services and is being evaluated in the Symptom Management Research Trials (SMaRT) Oncology series of randomized controlled trials. The intervention is an extended form of the collaborative care model and is delivered by a care manager, who receives regular supervision from a psychiatrist. The care manager coordinates the patient's depression management, by liaising with both their primary care physician and their cancer team, and provides a brief talking treatment. This article describes the design and delivery of DCPC as given in the SMaRT Oncology trials.     

Status of first-episode psychosis patients presenting for routine care in a defined catchment area.

OBJECTIVE: To examine the clinical and behavioural status of all first-episode psychosis (FEP) patients admitted to hospital within a defined catchment area. METHOD: We used a structured format to review clinical records of all first admissions to hospitals from a catchment area (population 390 000) with diagnosis of a first episode of nonaffective psychosis over a 3-year period. RESULTS: Patients were somewhat older than usually reported for FEP (mean age 31.3 years). They were mostly male (63.7%), single (80.8%), unemployed (87.4%), with a primary diagnosis of schizophrenia spectrum psychoses (85%), and had spent a mean of 31 days in an open inpatient unit and 2.93 days in an intensive care psychiatric unit during their first admission. Most (60.3%) were admitted involuntarily; 34.2% had a history of legal involvement; 18.8% had attempted suicide prior to admission; 31.5% had demonstrated violence toward people, property, or animals; 14.4% had suffered injuries; and 15.9% had shown aggressive behaviour during the hospital admission. CONCLUSIONS: These results identify some of the potential needs of FEP patients, toward whom early intervention services should be directed.     

Community care for people with psychosis: Outcomes and needs for care

People with psychosis living in developed countries in the era of community-based care are likely to be socially isolated, unemployed, and have poor quality of life, despite recent advances in the treatment and understanding of psychosis. Recent work in Australia illustrates the needs for care, especially for those with complex disabilities, and even for those in contact with well-organized clinical mental health services. Insufficient evidence in two key areas impedes progress: the use of effective psychosocial interventions; and the impact of changes in the community care system. Follow-up studies of programs and interventions assessing a range of outcomes in local settings are now required to encourage professionals and the community to address these needs.     

Community care for people with psychosis: outcomes and needs for care

People with psychosis living in developed countries in the era of community-based care are likely to be socially isolated, unemployed, and have poor quality of life, despite recent advances in the treatment and understanding of psychosis. Recent work in Australia illustrates the needs for care, especially for those with complex disabilities, and even for those in contact with well-organized clinical mental health services. Insufficient evidence in two key areas impedes progress: the use of effective psychosocial interventions; and the impact of changes in the community care system. Follow-up studies of programs and interventions assessing a range of outcomes in local settings are now required to encourage professionals and the community to address these needs.