Yorkshire and the Humber Mental Health Network Early Intervention in Psychosis Network 7 th July 2016 • Stephen McGowan, EIP Clinical Lead for Y&H CN and NHSE (North) • Dr Steve Wright, Consultant Psychiatrist, TEWV (Co-Chair) • Rebecca Campbell, Quality Improvement Manager and Sarah Boul, Quality Improvement Lead • Rebecca.campbell6@nhs.net and sarah.boul@nhs.net • Twitter: @YHSCN_MHDN #yhmentalhealth • July 2016 www.england.nhs.uk
Yorkshire and the Humber Early Intervention in Psychosis Network Welcome! Introductions Aims, Objectives and Terms of Reference Steve Wright, Consultant Psychiatrist, Tees Esk Wear Valleys NHS Trust www.england.nhs.uk
Housekeeping: @YHSCN_MHDN #yhmentalhealth www.england.nhs.uk
Aims, Objectives & Terms of Reference (1) Scope • The key focus of this group will be the implementation of the new mental health access and waiting time standards, and the NICE Guidelines. • The group will also act as a community of interest in the issue of Early Intervention in Psychosis and related mental disorders that affect young people and their families. www.england.nhs.uk
Aims, Objectives & Terms of Reference (2) Aim - 1 • In line with IRIS, the Network will influence service developments that improve the lives of people affected by psychosis and their families by embracing the aims and principles of the Early Psychosis Declaration: • Improve access, engagement and treatment of young people with emerging psychosis • Recognise the importance of recovery and ordinary lives for those with early psychosis • Support families and close friends who are dealing with the impact of early psychosis in a person they care about • Raise community awareness about the importance of early intervention for psychosis • Help practitioners from community and specialist mental health services deal more effectively with early psychosis
Aims, Objectives & Terms of Reference (3) Aim - 2 • Ensure delivery of the regional EIP preparedness programme: • Raising awareness of the requirements of the new standard • Bringing together local experts and establishing quality improvement networks, ensuring effective linkage with strategic clinical networks • Understanding levels of demand in constituent CCGs and any inequities in access relative to the levels and patterns of psychosis incidence in the population • Understanding baseline performance and act on the gap analysis • Optimising referral to treatment pathways, engaging all of the likely referral sources • Preparing for the new data collection requirements and providing training for EIP service and information leads • Supporting local workforce development programmes
Aims, Objectives & Terms of Reference (4) Aim - 3 • In addition the Network will support the following: • Information exchange • Networking • Sharing good practice • Sharing resources e.g. job descriptions, operational policies etc. • Identifying common problems and seeking solutions • Areas with strengths and/or expertise will offer support to areas with developmental needs. • Education • Dissemination of information and communication from the National Team
Aims, Objectives & Terms of Reference (5) Role • Unite individuals and partners across Yorkshire and the Humber in a common purpose. • Promote common understanding, joint working and prevent duplication. • Work collaboratively to build capacity and capability for quality improvement in services.
Aims, Objectives & Terms of Reference (6) Sign off? • Any comments or suggestions prior to sign-off. • Review in 6 months
Y&H EIP Steering Group Overview: • Purpose is to provide a mechanism for agreeing EIP priorities for the region • In addition to oversee the Y&H EIP Network. • Membership representative both of the geography of region and also of the key roles in EIP, including service user and carers. Comments & Feedback from the first meeting
Yorkshire and the Humber Early Intervention in Psychosis Network National and Regional Update Moggie McGowan, EIP Clinical Lead (Yorkshire & The Humber), NHS England North www.england.nhs.uk
Yorkshire and the Humber Early Intervention in Psychosis Network EIP Audit – Self Assessment Tool https://www.snapsurveys.com/wh/s.asp?k=146616273215 www.england.nhs.uk
A DISCOURSE ON THE PSYCHOPHARMACOLOGY OF FIRST EPISODE PSYCHOSIS And an Historically Inaccurate and Whiggish Illustration of the Quandaries of Diagnosis as pertaining to Modern Psychiatric Practice , leaning on the work of Messrs Curtis and Elton Presented By Dr Iain Macmillan Consultant Psychiatrist EIP, Gateshead , NTW NHS Trust Honorary Clinical Senior Lecturer, Newcastle University And Regional EI Clinical Lead for Psychiatry, NHS England, North
EDMUND – ANNO 1590
HAS BEEN UNWELL Generalised malaise Symptoms - • Cough at night disrupting sleep • Pain in chest causing anguish • Swelling of the ankles – unsightly and uncomfortable Seeking help
DOCTOR 1 Heart ache disorder (melancholia) is the problem! Imbalance of the humours, excess black bile!
PX EXTRACT OF WILLOW BARK
DOCTOR 2 Nocturnal cough disorder is the prime problem, - Imbalance of the humours -excess phlegm.
PX DRAUGHT OF OPIUM
DOCTOR 3 The previous Doctors are fools and quacks, the primary problem is swollen ankle disorder - caused by a humoural imbalance – sanguinity (excess blood ).
PX LEECHES
EVIDENCE – BASED LEECH THERAPY Doctor: You know the leech comes to us on the highest authority? Edmund: Yes. I know that. Dr Hoffmann of Stuttgart, isn't it? Doctor: That's right, the great Hoffmann. Edmund: Owner of the largest leech farm in Europe….
DIFFERING OPINIONS Different focus on presenting symptoms Different explanations of aetiology Different treatments offered All to some extent effective
WILLIAM HARVEY – PARADIGM SHIFT
DE MOTU CORDIS, 1628
AND THE POINT OF THIS TALE – PSYCHIATRIC DIAGNOSES…. Essentially descriptive: constructed in the age of steam Observations of people with severe, established illnesses Syndromes (poorly validated) equated with Diseases Very few categories meet validity standards Aetiological assumptions underpin diagnoses OPCRIT rescued Psychiatry to some extent Reliability OK in research settings, poor in clinical ones Poor utility of diagnoses for treatment selection, research
Back to the 21 st Century…. Paradigm shift in progress?
Where am I now?
Bed Days – NHS resources – “current practice” doesn’t seem to be working terribly well…. Contribution of psychiatric disorders to occupation of NHS beds: analysis of Hospital Episode Statistics. Parvathy Pillay, Joanna Moncrieff DOI: 10.1192/pb.bp.109.028399 Published 31 January 2011
Pathophysiology
The black box of pathophysiology Aetiology Mechanisms Syndromes Genetics Depression Environment Childhood adversity Psychosis Stress Anxiety Drug abuse
Opening the black box of pathophysiology - • Dopa/mine – implicated Howes et al Arch Gen Psychiatry. 2009;66(1):13-20
Opening the black box of pathophysiology – neuroinflammatory processes? Bloomfield et al. AJP in Advance (doi: 10.1176/appi.ajp.2015.14101358)
Opening the black box of pathophysiology -
Opening the black box of pathophysiology - Autoimmune encephalitis • Anti-VGKC complex(2005, 2010) • LGI1 • CASPR2 • Anti-NMDA receptor (2007) • Anti AMPA receptor • GABA-B receptor • Anti GAD • Gly-R • Thyroid peroxidase TPO (Hashimoto’s)
Opening the black box of pathophysiology Maybe not just dopamine -
Effects of antipsychotics on inflammatory markers in schizophrenia: CATIE study Olanzapine Risperidone Quetiapine Perphenazine Ziprasidone CRP 0.70 change 0.60 (mg/L) 0.50 0.40 0.30 0.20 0.10 0.00 0 3 6 12 18 Visit (month) C-reactive protein (CRP) changes: olanzapine vs perphenazine (p<0.001) and olanzapine vs ziprasidone (p=0.003) Meyer et al 2009
Diagnoses
Where are we now? From the chair of the DSM IV group? “we are at the epicycle stage of psychiatry where astronomy was before Copernicus and biology before Darwin. Our inelegant and complex current descriptive system will undoubtedly be replaced by … simpler, more elegant models. ” Frances AJ, Egger HL: Whither psychiatric diagnosis. Aust N Z J Psychiatry 1999; 33:161 – 165
DSM III-R Diagnoses in FEP cohort Macmillan et al, Early Intervention in Psychiatry 2007
Pluripotential Early Stages with Growing Syndrome Clarity? mania depression mania depression mania depression Psychosis psychosis psychosis schizophrenia Stage 1a Stage 1b Stage 2+
Neurodevelopmental-staging model of psychosis (T.R. Insel, Nature 2010; 468;187-193)
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