Care pathways, DUP and access to early intervention in psychosis services. What’s good, what’s bad and how can we make it better? Max Birchwood 13/11/2015
Did the introduction of EI teams reduce DUP in UK?
The National/SUPER EDEN sites Lancashire + Wirral 5 teams (Marshall/Lewis/Sharma) Birmingham 5 teams (Birchwood/Lester) East Anglia 4 teams (Jones/Fowler) Cornwall 2 teams (Amos/Harrison)
Is there a critical period for DUP?
N=1027, UK National EDEN study Marshall et al, in submission
So have EI teams sorted the DUP/ treatment delay problem? Still late intervention for ~ 1/3
DUP in UK (the National EDEN study)
Let’s blame the GPs?
Duration of Untreated Psychosis – component delays Duration of Untreated Psychosis Onset Treatment Help seeking delay First help-seeking Delay in first ref to MHS Referral to MHS Delay within MHS Treatment Delay in ref to EIS Ref to EIS
1/3 still have long DUP (> 6 months) Birmingham EIS: over 20 years old, but still long DUP for many
Why is DUP still so long?
1/3 still have long DUP (> 6 months) Mostly accounted for by delays within mental health services
DUP > 6months characterised by… • More severe positive symptoms and general psychopathology at entry into Early Intervention Services • Younger age of onset (average 19 vs 21) • 41% under 18yrs at onset (majority between ages of 16 – 18)
Impact of the first mental health contact CAMHS/CMHTs linked to longer DUP
Why does first contact with CMHT/CAMHS prolong DUP? Premature discharge from CMHT common lengthens DUP
Why? Delays access to EIS, which prolongs DUP
How short do delays in mental health services etc, need to be?
The position of EIS in care pathway critical Generic access pathways prolong DUP
Can DUP be reduced in the UK context?
Interventions to reduce DUP: what works? • Review - Lloyd-Evans et. al., 2011, BJPsych • Multi-focused initiatives (eg TIPS) – mixed results • GP focused initiatives (LEOCAT (London), REDIRECT (Birmingham) found no significant effect on DUP • EIS have reduced DUP (N EDEN)
“Successful interventions to target treatment delays, therefore, will require greater understanding of the context within which they occur” Lloyd-Evans, et al 2011.
Birmingham pathways study: A quasi-experimental pilot trial Care pathway change (16-25 service) Psychosis awareness campaign
Psychosis awareness Campaign Launched January 7 th 2012 in local supermarkets Patient and public involvement • Posters, postcards & ‘give-aways’ • Bus/street advertising • Mail drops • Special events (flashmobs; music and art • exhibitions) Community events • Regular spots in community press and on • community websites; Direct link to Psychosis page on website • Information line • Reducing delay in the first treatment of psychosis in Birmingham, UK
Information line: A dedicated information line for anyone wanting further details about psychosis Manned by trained Advisors 0121 301 5858 Daily – 1 – 4.30 Reducing delay in the first treatment of psychosis in Birmingham, UK
www.youthspace.me/psychosis Reducing delay in the first treatment of psychosis in Birmingham, UK
Primary outcome: DUP Secondary outcomes: Help-seeking delay; Delay in MH services Reducing delay in the first treatment of psychosis in Birmingham, UK
DUP and components in target and control areas. Relative risk for the reduction in DUP for South = 0.736 (95% CI 0.350 to 0.893; p=.0039)
Conclusions • EIS can reduce treatment delay in MHS and DUP, but lots still to do • Access to EIS a critical factor in stopping the DUP clock • But DUP clock ticks while YP tries to access EIS • CMHT/CAMHS tend to prolong DUP as YP disengages or psychosis not recognised. • Care pathway to EIS crucial: ‘whole youth pathway’ can help.
Thank you m.j.birchwood@warwick.ac.uk
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