Aims of presentation: What is psychosis? Why were Early Intervention in Psychosis Services set up? What do they offer? How successful are EIP services? Why is there a new target associated with these teams? What could you do if there is a delay in your patient being seen?

What is Psychosis? An ‘umbrella’ term used to describe disorders that are usually severe and which feature delusions, hallucinations, or unusual or bizarre behaviour, often used when a more precise diagnosis cannot yet be made. May subsequently receive a diagnosis such as Schizophrenia, Delusional disorder, Drug/Alcohol related psychosis, Affective Psychosis, or Organic Psychosis etc Individuals who develop psychosis or schizophrenia will each have their own unique combination of symptoms and experiences, which will vary depending on their particular circumstances.

PEPS: Pre-Emptive Psychosis Symptoms (Bebbington, 1995) One Point Each The family is concerned Excessive use of alcohol Use of street drugs (including cannabis) Arguing with friends and family Spending more time alone  Two Points Each Sleep difficulties Poor appetite Depressive mood Poor concentration Restlessness Tension or nervousness Less pleasure from things

Three Points Each Feeling people are watching you* Feeling or hearing things that others cannot* Five Points Each Ideas of reference* Odd beliefs Odd manner of thinking or speech Inappropriate affect Odd behaviour or appearance First degree family history of psychosis plus increased stress or deterioration in functioning* Twenty points or more suggest psychiatric referral If any items marked with * are disclosed, consider a psychiatric referral to the Early Intervention in Psychosis Team. (Even if the score is less than twenty)

What is Early Intervention in Psychosis all about? Deciding if a psychotic process has started Offering help at the earliest opportunity Providing interventions for up to 3 years The drivers behind these services included; NHS plan, NSF,PIG (Policy Implementation Guidance 2001),Newcastle declaration 2002,WHO declaration, Service users, families & friends, Rethink……

What “intervention”? Biopsychosocial model of care in its truest sense. Input tailored to individual needs & Recovery focussed. Accepting of diagnostic uncertainty, up to 3 months assessment period Pro- active approach ( >50% used to disengage by year 1, with EIP approx 30% Doyle 2014, but in Notts approx 8.2% from 1.14.2014-17.11.2015 we discharged 232 people in total and 26 were discharged due to non-engagement All patients on CPA & have a care co-ordinator with capped case loads Low dose medication, choice offered

Interventions contd. Physical health monitored ( eg new clinic) Psychological input, use of CBT approach, Clinical Psychologist, BFT, CBT clinic for anxiety & or depression Social Inclusion Team- employment, education advice, social activities and building of social skills, individual and group work, “People do not recover in isolation. Recovery is closely associated with social inclusion and being able to take on meaningful and satisfying social roles within local communities” (Making Recovery a Reality, 2008)

What are the economic benefits of EIP services? If everyone who needed an EIP service got it, it would save the NHS £44 million a year. NICE Costing statement 2014. Commissioners and service planners can be confident that upstream investment in a more intensive evidence-based approach can save in the order of £5,000 in year one, rising to £14,000 by year three per case compared to treatment as usual (McCrone et al 2009).

And the human benefits? 35% of EIP in employment, compared with 12% in traditional care; reduce compulsory treatment from 44% to 23% during the first two months of psychosis reduce a young person’s suicide risk from 15% to 1%. Achieving Better Access to Mental Health Services by 2020,

Nottingham EIP Patients 44% are in Education, volunteering or employment. 34% are in more than 16 hours. 15% of caseload full time employed.

A Quality Standard: Treating Psychosis is a high priority area and is expected to contribute to improvements in the following outcomes: severe mental illness premature mortality employment and vocational rates hospital admissions referral to crisis resolution and home treatment teams service user experience of mental health services detention rates under the Mental Health Act. It is all about parity of esteem between physical and mental health.

NICE Guidelines Statement 1. Adults with a first episode of psychosis start treatment in early intervention in psychosis services within 2 weeks of referral. (The 2‑week timeframe is based on Achieving better access to mental health service by 2020 (2014) Department of Health and expert consensus) Statement 2. Adults with psychosis or schizophrenia are offered cognitive behavioural therapy for psychosis (CBTp). Statement 3. Family members of adults with psychosis or schizophrenia are offered family intervention

Statement 4. Adults with schizophrenia that has not responded adequately to treatment with at least 2 antipsychotic drugs are offered clozapine. Statement 5. Adults with psychosis or schizophrenia who wish to find or return to work are offered supported employment programmes. Statement 6. Adults with psychosis or schizophrenia have specific comprehensive physical health assessments. Statement 7. Adults with psychosis or schizophrenia are offered combined healthy eating and physical activity programmes, and help to stop smoking. Statement 8. Carers of adults with psychosis or schizophrenia are offered carer‑focused education and support programmes.

BY APRIL 2016… 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. Clock starts when referral received & Clock stops when patient accepted, allocated care co-ordinator and NICE recommended package of care has commenced Applies to people of ages!

How to refer: Write a detailed letter to the Single Point of Access, based at Highbury Hospital, without delay and state that you would like an assessment for a possible psychosis. If acutely unwell/high risk, consider CRHT In the past financial year had 157 referrals to City EIP, 77 ( 49%) were from Gp’s. We had 147 discharges and 36.1% were discharged back to primary care from EIP Do not start antipsychotic medication for a first presentation of sustained psychotic symptoms in primary care unless it is done in consultation with a consultant psychiatrist ( NICE)…….

What else can you do? Be aware that the assessment process can take time We recommend that psychiatrists are very cautious about making a diagnosis of schizophrenia, in particular after a first episode of psychosis; at that point making such a diagnosis may do more harm than good. The term psychosis, though far from perfect, does not convey the same pessimism and fear. (Schizophrenia Commission report 2012) Be hopeful and optimistic of recovery, most do recover, preventing relapse is key Support the family; having a family member who has psychosis can be very stressful

What to do if you are waiting for EIP to start the assessment? If there is going to be a delay, EIP should let you know (new GP liaison pilot plan) If you are thinking of starting treatment, discuss this with a Psychiatrist in the local EIP service and follow NICE guidance on actions prior to prescribing and monitoring Consider seeing the patient weekly if appropriate, monitor risk, if it increases and is urgent, consider CRHT

Choosing antipsychotic medication The choice of antipsychotic medication should be made by the patient and healthcare professional together, taking into account the views of the carer if possible. Information verbally and in writing about the likely benefits and possible side effects of each drug should be provided, including: metabolic, extrapyramidal, cardiovascular (including prolonging the QT interval), hormonal (including increasing plasma prolactin) and others. At the start of treatment a dose at the lower end of the licensed range is usually given and slowly titrated upwards within the dose range.

Baseline investigations ( NICE says…) Before starting antipsychotic medication, undertake and record the following baseline investigations: weight (plotted on a chart) waist circumference pulse and blood pressure fasting blood glucose, HbA1c, blood lipid profile and prolactin levels assessment of any movement disorders assessment of nutritional status, diet and level of physical activity.

AND….. Before starting antipsychotic medication, offer the person with psychosis or schizophrenia an ECG if: specified in the SPC eg Haloperidol a physical examination has identified specific cardiovascular risk (such as diagnosis of high blood pressure) there is a personal history of cardiovascular disease or the service user is being admitted as an inpatient.

Monitoring antipsychotic medication Monitor for side effects of treatment including the emergence of movement disorders, monitor adherence and over all physical health Weight, weekly for the first 6 weeks, then at 12 weeks, at 1 year and then annually (plotted on a chart) Waist circumference annually (plotted on a chart) Pulse and blood pressure at 12 weeks, at 1 year and then annually

And…. Fasting blood glucose, HbA1c and blood lipid levels at 12 weeks, at 1 year and then annually According to NICE, the secondary care team should maintain responsibility for monitoring service users' physical health and the effects of antipsychotic medication for at least the first 12 months or until the person's condition has stabilised, whichever is longer. Thereafter, the responsibility for this monitoring may be transferred to primary care under shared care arrangements.

What the Schizophrenia Commission think of EIP.. “Early intervention is crucial to improving outcomes. The Commission’s view is that Early Intervention in Psychosis (EIP) has been the most positive development in mental health services since the beginning of and families and there is a clear evidence of their ecommunity care. These services are popular with service users ffectiveness. Staff who work in them are positive, committed, they enjoy their work and tend to be well led.”

Useful websites http://www.choiceandmedication.org/nottinghamshirehealthcare http://www.nottinghamshirehealthcare.nhs.uk/ http://www.rcpsych.ac.uk http://www.patient.co.uk http://www.nhs.uk/ http://www.iris-initiative.org http://nice.org.uk http://rethink.org http://mind.org.uk http://sane.org.uk