EIS Training Forum Wellington, New Zealand 24th November 2015 Case Management in Early Psychosis Part 2 Dr Craig A Macneil Senior Clinical Psychologist/ Case Manager Early Psychosis Prevention & Intervention Centre (EPPIC)/ EPPIC Statewide Melbourne, Australia EIS Training Forum Wellington, New Zealand 24th November 2015

- Rosen, AusEinet Keynote, 1999 “(Case Managers)... combine the skills and roles of a clinician, rehabilitation coach, mentor, advocate, and trusted ally” - Rosen, AusEinet Keynote, 1999

SIGN Guidelines (p.5)

SIGN Guidelines (p.5)

SIGN Guidelines (p.5)

SIGN Guidelines (p.5)

SIGN Guidelines (p.5)

SIGN Guidelines (p.5)

(p.S41)

Four randomised controlled trials of early intervention services (COAST, LEO, OPUS and EPPIC) (n=800). Found that early intervention; reduced hospital admission, reduced relapse, reduced positive symptoms, reduced negative symptoms, patients significantly more likely to receive psychological intervention, more likely to remain in contact with services (i.e. better engagement), patients were less likely to drop-out. LEO study found that EI was associated with better engagement, reduced relapse and readmission. Craig et al., (2004) OPUS study found EI superior in terms of engagement, lower readmission rates, symptoms , family contact and improved quality of life compared to standard CMHT based care (Petersen et al 2005 At 5 year follow up, EI group had more independent living and fewer days in hospital OPUS ( Bertelsen et al 2008) Mihalopoulos et al., (2009) found that almost 8 years after initial treatment, patients treated within EI displayed lower levels of positive psychotic symptoms, were more likely to be in remission, and had a more favorable course of illness than the controls 14

“It is not the duty of the case manager to do everything, but to ensure that all is done.” - Rosen, AusEinet Keynote, 1999 Rosen AusEINet 1999 Adelaide 1999 (Case managers) ...combine the skills and roles of a clinician, rehabilitation coach, mentor, advocate, and trusted ally.... It is not the duty of the case manager to do everything, but to ensure that all is done.

Biopsychosocial model Stress-vulnerability model with interventions being dependent on phase of disorder

phase – specific approach

The Phases of Psychosis Time Severity of symptoms The Phases of Psychosis Acute - Mean 1-2 years prior to starting treatment Late Recovery -12 months to 2 years following first episode Prodrome - Median time 2 years Early Recovery -remission of positive symptomsMedian time 11 weeks. Incomplete Recovery - persistent symptoms Point out that in the past clinically a focus has been on recovery from positive symptoms of psychosis. Participants will be familiar with the diagram in this slide which is often used to describe the different phases of psychosis in first episode psychosis. Remind participants of the definition of Early Recovery & Late Recovery Early Recovery phase commences when there is an initiation of treatment The pattern of recovery varies from person to person. During the recovery phase acute symptoms remit. Lieberman et al. (1993) reported that the mean interval between initiating medication and achieving maximum improvement was 36 weeks with a median of 11 weeks. It is a huge variance, but does show that we can aim for shorter times in achieving improvement, especially as there were based on people taking FGA’s. Up to 85-90% of people with a first episode of psychosis will achieve a remission or partial remission of their positive psychotic symptoms within 12 months of initiation of treatment. This figure varies from study to study with the best being about 91% to some as low as 70% During the late recovery phase functional recovery occurs, but we can look at who is at risk of poorer functional recovery early on in treatment. We will discuss this later. Highlight to participants that these definitions are very much focussed on the presence of persistent positive symptoms and that boundaries identified for different stages of psychosis are arbitrary; in practice it is more complicated than a categorical approach. Use this slide to segue into the next slide RJBell 08 19

acute Tasks: Develop therapeutic relationship Comprehensive assessment & formulation Provide appropriate information to young person & family Medication adherence ‘Damage control’

recovery Tasks: Prevent secondary morbidity Assess & monitor progress Continued psychoeducation Assist in re-integration to society Work on managing any persisting symptoms (e.g. voices, delusions) Minimise risk of relapse

80% of people will have their first psychotic episode between ages 15-30 Getting in Early - A Framework for Progress in Early Intervention and Prevention in Mental Health for Young People in NSW (1999)

(p.S41)

Case Management “(Case Managers)...combine the skills and roles of a clinician, rehabilitation coach, mentor, advocate and trusted ally” “Case managers carry considerable responsibility...it is their responsibility to ensure that all the necessary components of long-term care are provided by the service” (CBCM manual, p. 16)

Four randomised controlled trials of early intervention services (COAST, LEO, OPUS and EPPIC) (n=800). Found that early intervention; reduced hospital admission, reduced relapse, reduced positive symptoms, reduced negative symptoms, patients significantly more likely to receive psychological intervention, more likely to remain in contact with services (i.e. better engagement), patients were less likely to drop-out. LEO study found that EI was associated with better engagement, reduced relapse and readmission. Craig et al., (2004) OPUS study found EI superior in terms of engagement, lower readmission rates, symptoms , family contact and improved quality of life compared to standard CMHT based care (Petersen et al 2005 At 5 year follow up, EI group had more independent living and fewer days in hospital OPUS ( Bertelsen et al 2008) Mihalopoulos et al., (2009) found that almost 8 years after initial treatment, patients treated within EI displayed lower levels of positive psychotic symptoms, were more likely to be in remission, and had a more favorable course of illness than the controls

(p.2229)

100% had inpatient admissions in CMHT (mean = 165.5 days) 100% had inpatient admissions CMHT + specialist EI workers (78.7 days) 33% had inpatient admissions in specialist EI service (45.1 days)

From: Cognitive Behavioural Case Management in Early Psychosis: A Handbook. OYHRC. (2010, p.18)

EPPIC staff training in: Historical overview & evidence-base of engagement Challenges to engaging young people with FEP Identifying helpful engagement techniques Managing ruptures Dis-engagement and terminating contact

(p.15)

(p. 70)

Percentage drop-out

Percentage dropout from treatment Pelkonen et al (2000) J Am Acad Child Adolesc Psychiatry only 17.8% attended 1 or 2 appointments Brorson et al (2013)– Clinical Psychology Review. Systematic review of 43% drop out from drug detox Psychiatr Serv. 2009 Jul;60(7):898-907. doi: 10.1176/appi.ps.60.7.898. Dropout from outpatient mental health care in the United States. Olfson M1, Mojtabai R, Sampson NA, Hwang I, Druss B, Wang PS, Wells KB, Pincus HA, Kessler RC. – 32% dropout from general medical sector

EPPIC Team B

EPPIC Team A 25 Case Managers across 2 sites (19.1 EFT) Up to 2 year period of care Current 304 clients

Professional Background of EPPIC Case Managers

Specialist, 16 bed, youth inpatient unit

Early identification Community wide education Increased research Phase-specific care Careful use of meds (drug naivety) Psychosocial interventions Consumer/ family involvement

(p.7)

43 publications, 28 sites, 5 countries (France, Canada, UK, Norway, Australia) (p.1785)

the evidence

symptomatology

n N=65 “Co-ordinated specialty care..” comprising: Medication Supported employment/ education Family support, Psychoeducation (individual & family) Social skills and “support based on cognitive behavioural methods, Substance abuse treatment Suicide prevention

Dropout rate of 10% at 2 years n N=65 “Co-ordinated specialty care..” comprising: Medication Supported employment/ education Family support, Psychoeducation (individual & family) Social skills and “support based on cognitive behavioural methods”, Substance abuse treatment Suicide prevention Dropout rate of 10% at 2 years

Audit of 704 EPPIC clients at completion of treatment

23.3% of EPPIC F.E.P. clients dropped out during 18 month period of care Conus et al., 2010

9422 GBP = 17,024 NZD 14394 GBP = 26,008 NZD 26568 GBP = 47,998 NZD 40816 GBP = 73,739 NZD Difference = 14,248 pounds 25,741 NZD over 3 years (p.266)

EI results in; reduced costs of lost employment (employment rates of 36% vs. 27% standard care). costs of homicide (£ 6 per person) are £ 80 per person lower than for standard care (£ 86 per person). suicide rates of 1.3% of EI patients vs. 4% of standard care patients. Annual saving in suicide costs due to EI is £ 957 per person. 6 GBP= 10.8 NZD 80 = 144.6 86 = 155.4 957 = 1729

(p.160)

2012 update (p.18)

guidelines

p.16-17

(p.16-17)

(p.2)

the practice

EIS Training Forum Wellington, New Zealand 24th November 2015 Case Management in Early Psychosis Dr Craig A Macneil Senior Clinical Psychologist/ Case Manager Early Psychosis Prevention & Intervention Centre Melbourne, Australia EIS Training Forum Wellington, New Zealand 24th November 2015

“The engagement phase is crucial in all forms of psychiatric treatment, with the strength of the therapeutic alliance a moderate-to-strong predictor of outcome, regardless of therapeutic approach, including with young people” (2010, p.67) OYHRC (2010). Australian Clinical Guidelines for Early Psychosis (2nd ed.)

Rhodes & Jakes (2009). Narrative CBT for Psychosis (p.45) “In the case of clients with psychosis initially their assessment of us is much more important than our assessment of them… The overriding question (of clients) will be ‘Will it be helpful or unhelpful to attend these sessions’”

Rhodes & Jakes (2009). Narrative CBT for Psychosis (p.45) “In the case of clients with psychosis initially their assessment of us is much more important than our assessment of them… The overriding question (of clients) will be ‘Will it be helpful or unhelpful to attend these sessions’”

Paradox that younger people are often more unwell, but Overwhelming evidence that early intervention leads to better outcomes symptomatically, functionally, & economically

Percentage drop-out

Percentage drop-out

Percentage drop-out

OYHRC (2010). Australian Clinical Guidelines for Early Psychosis (2nd ed.) “This suggests that early intervention may need to be sustained to be effective” (2010, p.67)

Engagement

Rhodes & Jakes (2009). Narrative CBT for Psychosis (p.45) “In the case of clients with psychosis initially their assessment of us is much more important than our assessment of them”

Relevant training, knowledge and skills Capability Relevant training, knowledge and skills

“Integrated, streamed specialist services provided in stigma-free community-based settings are more effective than standard adult mental health services in the treatment of people experiencing first episode psychosis” (2010, p.10)

(HM Govt, 2011)

64,948 AUD (2011, p.66)

Case Management: “An Opportunity to Optimise Care”

(p.15)

(p.15)

Case Management

But do we need specialist EI services?

craig.macneil@mh.org.au