Treatments for psychosis; how the NHS has pioneered new research and service models to improve outcomes. Paul French

Promoting recovery in psychosis For many years a diagnosis associated with psychosis was assumed to be catastrophic. Don’t talk to people about their hallucinations. Stories of clinicians saying you would be better off with cancer. We have known about 20 year loss of life compared to peers for a long time. “all these recovery messages not helpful for those people that don’t recover”

Perceptions of mental health and mental illness have changed BUT these campaigns tend to focus on anxiety depression eating disorders and its clearly vital to reduce stigma in these areas but there remains very little to challenge stigma of psychosis

This advertising campaign by rethink highlighted the value we plced on mental health when the nice man from the AA/RAC turned up in 60 minutes but for your mind it’s a whole different approach. The average delay in access to treatment called duration of untreated psychosis was around 12 months and we worked to change that locally to 12 weeks but wanted to challenge that even further.

Policy Implementation Guidelines Introduction of EIP services in 1998 as part of the National Service Framework Promoted the importance of working with people in their First Episode of Psychosis

What does an early psychosis team do 1. Highlighted the possibility to prevent psychosis in the ultra high risk individuals 2. Reduce DUP (Duration of Untreated Psychosis): 3. Optimise initial experience of acute care & treatment: 4. Maximise recovery & prevent relapse during critical period:

Age of onset for schizophrenia Females % Males % 35 30 25 20 Percentage 15 10 EIP services were specifically constructed to bridge the CAMHS AMHS gap to ensure that young pople with emerging psychosis didn’t fall between the two service structures and the gap that was fairly artificially created right at the time when young people were starting to experience emerging mental health conditions - including psychosis The The teams were set up to be youth orientated. 5 age age age age age 30 age age age age 50 age 12-14 15-19 20-24 25-29 34 35-39 40-44 45-49 54 55-59

“The jewel in the crown of the NHS mental health reform because: Service users like it People get better It saves money” Professor Louis Appleby; Track conference Birmingham April 29th 2009

Lost generation report published by RETHINK 2014

Ministerial announcement Norman is an incredible MH advocate who has fought tirelessly for MH services and people who use them. He wanted to ensure the introduction of the first waiting times standard for MH – physical heath has had them for a number of years in parts of the system like A&E and Cancer services and he had visited lots of services across the country and consulting with staff and service users felt that psychosis should be the MH equivalent of cancer in that its an awful condition that can lead to loss of life BUT if caught early and with the right treatment recovery was not only possible but likely. Ministerial announcement huge support from Norman Lamb – parity of esteem reflecting the act that there were no access and waiting times standards for mental health and psychosis was considered to be the one of the most crucial areas that intervening early could have a big impact This wasa huge ca;;enge to the system – as you saw from the rethink report 50% of services had their budgets cut and we avtually lost a number of EIP teams across the country. Our organisation GMMH was about to reintegrate the EIP teams back into CMHTs which would have been a retrograde step. The move to deliver the AWT standard changed all that with a recognition that to achieve it would require significant funding in the workforce not just in terms of people but also training.

Access and Waiting Times Standard for Psychosis More than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral (Rising to 60% by 2020) 2 parts Part 1 - get people access quickly 2 weeks Part 2 – get people the right interventions Ministerial announcement huge support from Norman Lamb – parity of esteem reflecting the act that there were no access and waiting times standards for mental health and psychosis was considered to be the one of the most crucial areas that intervening early could have a big impact This wasa huge ca;;enge to the system – as you saw from the rethink report 50% of services had their budgets cut and we avtually lost a number of EIP teams across the country. Our organisation GMMH was about to reintegrate the EIP teams back into CMHTs which would have been a retrograde step. The move to deliver the AWT standard changed all that with a recognition that to achieve it would require significant funding in the workforce not just in terms of people but also training.

How are we doing Across England 75% of people sen within 2 weeks 93% within 6 weeks and 98% within 12 weeks – dramatically improving the life chances of people with emerging psychosis.

Interventions to maximise outcomes associated with a First Episode of Psychosis Referral to EIP and start treatment within 2 weeks Offer CBT for Psychosis Offer Family Interventions Offer Clozapine (if not responded to other meds) Provide Supported Employment Programmes Assessment of Physical Health Promoting Healthy Lifestyles (exercise, smoking cessation, diet) Offer carer focused education and support This is an opportunity to highlight the vital work of researchers in England who have developed CBT for psychosis and helped the major shift of amphasis of talking to people about their psychosis symptoms. Same in terms of Family based interventions – Nick Tarrier and Christine Barrowclough from Manchester have been seminal in developing these approaches. Major work in Egland to develop interventions for physical health care provision.

Alvarez-Jimenez et al; CNS Drugs, 2008 22: 547-562 Antipsychotic-Induced Weight Gain in Chronic and First-Episode Psychotic Disorders: a Systematic Critical Reappraisal 20 Established Psychosis RCTs Established psychosis RCTs 3 kg 15 4 kg kg 10 12 kg 5 First episode of psychosis RCTs 12 24 36 48 Months Alvarez-Jimenez et al; CNS Drugs, 2008 22: 547-562

Jo Hodgekins, Paul French, Max Birchwood, Miranda Mugford, Rose Christopher, Max Marshall, Linda Everard Helen Lester, Peter Jones, Tim Amos, Swaran Singh, Vimal Sharma, Anthony P. Morrison, David Fowler Schizophrenia Research 2015

In conclusion EIP services are well and truly embedded within clinical practice right across the NHS in England Theses services have achieved a huge amount over the past couple of years to see people within a 2 week time frame – internationally recognised We are now evaluating what interventions are offered to individuals and their families to promote recovery and measuring whether this is achieved We are the only country in the world that measure delays to services for people with psychosis in days and weeks not months and years. Cancer UK – more than 25,000 patients joined clinical trials last year - we need to encourage research across our services and ensure people get access to early trials and we make the most of research opportunities.

Thank you Paul.french@gmmh.nhs.uk @pfrench123