Early Intervention in Psychosis Network 7 th July 2016 Stephen - - PowerPoint PPT Presentation

www.england.nhs.uk

• 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

Yorkshire and the Humber Mental Health Network

Early Intervention in Psychosis Network 7th 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

@YHSCN_MHDN #yhmentalhealth

Housekeeping:

www.england.nhs.uk

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.

Aims, Objectives & Terms of Reference (1)

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 (2)

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 (3)

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 (4)

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 (5)

Sign off?

• Any comments or suggestions prior to sign-off.
• Review in 6 months

Aims, Objectives & Terms of Reference (6)

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

Y&H EIP Steering Group

www.england.nhs.uk

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

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

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…. EVIDENCE –BASED LEECH THERAPY

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

 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

AND THE POINT OF THIS TALE – PSYCHIATRIC DIAGNOSES….

Back to the 21st Century…. Paradigm shift in progress?

Where am I now?

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

Bed Days – NHS resources – “current practice” doesn’t seem to be working terribly well….

Pathophysiology

The black box of pathophysiology

Genetics Stress

Syndromes Aetiology Mechanisms Depression Anxiety

Drug abuse Childhood adversity

Psychosis

Environment

• Dopa/mine – implicated

Opening the black box of pathophysiology -

Howes et al Arch Gen Psychiatry. 2009;66(1):13-20

Bloomfield et al. AJP in Advance (doi: 10.1176/appi.ajp.2015.14101358)

Opening the black box of pathophysiology – neuroinflammatory processes?

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

C-reactive protein (CRP) changes:

• lanzapine vs perphenazine (p<0.001)

and olanzapine vs ziprasidone (p=0.003) Meyer et al 2009

0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 CRP change (mg/L) 3 6 12 18 Visit (month) Olanzapine Perphenazine Risperidone Ziprasidone Quetiapine

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?

psychosis mania depression psychosis depression mania Psychosis depression mania

Stage 1a Stage 2+ Stage 1b

schizophrenia

Neurodevelopmental-staging model of psychosis

(T.R. Insel, Nature 2010; 468;187-193)

Stage Definition Interventions

Increased risk of psychosis or mood disorder (eg family history, abuse, substance use) No specific symptoms currently Mental Health Literacy Self-Help

1a

Mild or non-specific symptoms of psychosis or mood disorder Mental Health Literacy Family Psychoeducation Substance abuse, CBT

1b

Prodromal features: Ultra High Risk 1a plus Therapy for episode: ? phase specific or MS

2

First Episode Threshold psychosis or mood Disorder 1b & case management, vocational rehabilitation

3a

Recurrence of sub-threshold psychosis or mood symptoms 2 & emphasis on maintenance meds and psychosocial strategies

3b

First threshold relapse 2a & relapse prevention strategies

3c

Multiple relapses 3b & Combination/ mood stabilisers

4

Persistent unremitting illness 3c & clozapine and other tertiary therapies.

A staging model

McGorry ANZ JP 2006; Berk et al. Bipolar Disord 2007; Berk et al. J Affective Disord 2007

Known biomarkers by clinical stage

Stage Structural MRI

• Hippocampus
• Frontal cortex
• Lateral ventricles
• Right superior temporal lobe
• Corpus callosum
• Amygdala

Neurocognition

• Intellectual impairment
• Executive function
• Verbal memory
• Working memory
• Sustained attention
• Response inhibition
• Symbol coding

Electrophysiology

• Impaired P50
• Deficits in P300
• Reduced mismatch

negativity

• Abnormalities in resting

state EEG spectra Neuroimmunology

• Increased proinflammatory

cytokines (eg IL6, IL1, TNFa)

• Increased antiinflammatory

cytokines (eg IL10) Oxidative stress

• Dysregulation of

antioxidant enzyme activity

• Increased lipid

peroxidation

• Mitochondrial

dysfunction HPA axis dysregulation

• Cortisol secretion
• Glucocorticoid receptor

activity

• Mineralocorticoid receptor

activity

• Pituitary volume

Sz BD MD Sz BD MD Sz BD MD Sz BD MD Sz BD M D Sz BD MD

IQ? CI? ? MMN ?

1a

IQ CI? ? MMN ? C GR

1b

FC STL ? ? IQ CI IQ? P50 P300 MMN EEG ? ? ? ? ? ? ? ? C ? ? C GR

2

HV FC LV STL CC ? A? IQ CI IQ CI CI? P50 P300 MMN EEG P50 P300 ? pro anti pro anti pro    C GR PV PV C PV GR MR

3

HV FC LV CC LV HV A? STL IQ C IQ CI CI? P50 P300 MMN EEG P50 P300 ? pro pro pro    C GR PV PV C PV GR MR

4

HV FC LV CC LV HV A? STL IQ CI IQ CI CI? P50 P300 MMN EEG P50 P300 ? pro pro pro    C GR PV PV C PV GR MR

Treatments

Stage 1b - ARMS

Antipsychotic medication

Medication requires expert and careful consideration as these typically young people, previously treatment naive, may be embarking on treatments which for some may be necessary for several years.

Stage 2 – FEP Antipsychotic medication

Most current antipsychotics show similar efficacy against positive symptoms in

• FEP. Thus choice of drug should be

based on tolerability and side effects experienced, and the individual’s ability to manage these whilst maintaining therapeutic benefit.

(Leucht et al 2009)

Stage 2 – FEP Antipsychotic medication

Leucht et al, Lancet 2013

Lieberman et al 2003

Medications – more useful when taken….

Leucht et al, Lancet 2013

Antipsychotic medication – low dose

Dose recommendations of atypical antipsychotics in first- episode non-affective psychosis – start low go slow!

Atypical Antipsychotic Starting Dose Initial Target Dose (to reach after 7 days, maintain for 3 weeks) Full (max) target dose (increase slowly over 4 weeks, total trial 8 weeks) Amisulpiride 50-100 mg daily 300 mg daily 800 mg daily Aripiprazole (1st line?) 10 mg daily 15-20 mg daily 30 mg daily Clozapine (not 1st or 2nd line) 25 mg test dose 100-150 mg daily 200-300 mg daily Olanzapine 2.5-5 mg daily 10 mg daily 20 mg daily (not recommended due to excess metabolic burden) Quetiapine

(?advantage in affective)

25 mg test dose 150 -400 mg daily 750 mg daily Risperidone (1st line?) 0.5-1 mg daily 2mg daily 4 mg daily

(Adapted from Lambert et al, Pharmacotherapy of first-episode psychosis,2003)

Dose Equivalents

Leucht et al, Schizophrenia Bulletin Advance Access Feb 2014

“An adequate trial….”

Antipsychotic medication This should be provided in conjunction with a psychosocial and vocational programme including physical, family interventions and CBT-p, delivered by a coherent specialist EIP service.

Antipsychotics – concerns arise

FGA vs SGA?

Some people may choose to avoid medication and should not be made to feel they are not cooperating. Indeed although difficult to predict who, evidence shows that some can do well without medication. Offer CBT, Family Therapy, CBT-informed case management. Antipsychotic medication

Stage 4 - Antipsychotic medication Following careful review, consideration should be given to the early use of clozapine in people whose symptoms do not respond to an adequate trial of two different antipsychotic agents.

Antipsychotic medication – discontinuation?

Wunderinck et al JAMA Psychiatry. doi:10.1001/jamapsychiatry.2013.19Published online July 3, 2013.

Antipsychotic medication in FEP – stages 2-3-4

• 1. Involve service users in treatment choices
• 2. Young, neuroplastic brains – be gentle!
• 3. Actively manage metabolic risk from the outset
• 4. Start low, go slow
• 5. Be sensitive to side effects
• 6. Don’t persist with ineffective treatments, but

give adequate trial at a decent (not high) dose

• 7. No clear guide as to 1st and 2nd choice,

?SGA>FGA, Risperidone/Aripiprazole?

• 8. Discontinuation possible once stably recovered

– gradual with clear plan to manage relapse

• 9. 3rd choice Clozapine

Thanks for listening!

• Any questions?

Thanks to Pat McGorry and Michael Berk for some of the slides. Edmund’s case developed from conversations with Michael Berk and Assen Jablensky. Thanks to Messrs Curtis and Elton.

Post Graduate Diploma in CBT (Secondary Care)

Kerry Smith 2015

Context:

• Professional training
• Funding from LETB to support local service

development imperatives

• Training for the Diploma and Certificate is at

level 7

• (Level 6 modules were offered as CPD

elements to support staff not ready to progress at academic level 7 or as a precursor)

Knowledge and Skills Specific to Secondary Care:

• CBT competencies – Common anxiety

disorders / mild to moderate depression (primary care)

• CBT competencies- Serious mental Illness

(secondary care )

• Supervision competencies

Training Pathways

PG Diploma:

• 4 taught modules and 2 supervised practice modules

i)Basic theories and skills, ii)Common disorders in SMI

iii)Psychosis and Bipolar, iv)PD and complex presentations

PG Certificate (theory):

• 3 taught modules ( one of these for SMI competencies)

PG Certificate with Clinical Practice (“Top-up”)

• 1 taught module (Psychosis and Bipolar Disorder)
• 2 supervised practice modules (Psychosis clients)

Trainees

• PG Dip: Current cohort: 23 (20)
• PG Dip: Cohort 2017: 23 offers
• Top- up : 4 (and counting)

Geography Served (in order of numbers)

• Humber
• Leeds
• Navigo
• Bradford
• Castleford
• Dewsbury
• Barnsley
• Scarborough
• Lincoln
• Other ( non NHS)

Service context

• Increasing Access to Psychological Therapies

(IAPT):

• primary care
• Children and young people
• Serious mental illness (SMI)
• EIP access standards
• NICE

Roth & Pilling competency framework

• Generic therapeutic competences

– E.g., client engagement, dealing with emotional content

• Basic CBT competences

– E.g., Structure, basic principles of cognitive psych and behaviourism

• Specific behavioural and cognitive therapy

– E.g., exposure, guided discovery, formulations

• Problem specific competences

– ‘Models’ of disorders such as PTSD, OCD etc.

• Metacompetences

– E.g., clinical judgement, choosing appropriate treatment interventions

http://www.ucl.ac.uk/clinical- psychology/CORE/CBT_Competences/CBT_Competences_Map.pdf

Problem specific competences

• http://www.ucl.ac.uk/clinical-

psychology/CORE/CBT_Competences/Problem _Specific_Competences/Problem_Specific_Co mpetences.pdf

Who comes on our training course?

Core Professional Groups:

• Nursing
• Social work
• Clinical Psychology
• Counselling Psychology
• Occupational Therapy
• Psychiatry

Applicants via a Knowledge Skills and Attitudes ( KSA)Route

• Applicants who can demonstrate knowledge

skills and attitudes equivalent of a core professional training.

• Need to submit a KSA portfolio at interview.

Can be completed during the course. But initial draft must indicate near readiness at interview

• General nurses, PWPs, Psychology Assistants,

Care coordinators

Selection

Application form:

• Needs to show service support and

permissions for training are in place Interview:

• Role play
• Reflection
• Questions

Teaching methods

• Teaching and guided reading: theory and practice
• Acting on knowledge in practice exercises in skills

sessions, self therapy and clinical practice.

• Applying knowledge to new areas of CBT theory

through academic writing: essays and exams.

• Reflecting on experiences by observation in

workshops, by recording own practice and using rating scales to structure this thinking, by using supervision.

Trainee feedback:

• Course is demanding
• Value high content of skills based teaching and

chance to observe practice

• (Always want more of this)
• The chance to focus on complex cases and

comorbidity is good preparation for work in any service

Predictors of successful training

• Jolley, S., Onwumere, J.,Kuipers, E., Craig, T.,

Moriaty, A. and Garety, P. (2014)

• Increasing access to Psychological therapies

for people with psychosis: Predictors of successful training.

• https://www.researchgate.net/journal/1873-

622X_Behaviour_Research_and_Therapy

Successful training:

• Previous work as a CBT therapist
• Current role as therapist
• Previous academic study at masters level

Delivery after training:

• Found many trained stopped delivering

therapy because of difficulties with workload and care- co duties

• Delivery is enhanced when therapists are

employed in dedicated posts

How services can support training

• Management support in preparation for training
• Supervisor identified early on (BABCP Accredited)
• Supervisor facilitated to attend course supervisor events
• Adequate recording facilities made available early on
• Access to appropriate clients facilitated
• Support given for seeing training cases for adequate numbers of sessions
• Support to attend all teaching sessions
• Support for study time if required
• Avoid dual roles for training cases where possible: care co-ordinator and

therapist

• Where service pressures prevent some of the practical measures above an

emotionally supportive environment can still help trainees to cope- trainees don’t expect unrealistic adjustments but need to know that mangers understand the extra challenges training involves

How services can support implementation of therapy post training

• Ensure that post training job roles allow dedicated time

for CBT practice and supervision

• Encourage CBT related CPD and consolidation
• Incorporate accreditation as a goal of staff appraisal
• Encourage investment in completing and consolidating

training rather than taking up multiple training

• pportunities without completion.
• Nurture successful trainees as assets that can benefit

colleagues through supervision and support and training

How we can support, post training?

• Supervisor workshops
• Masterclasses
• Support for accreditation
• Involvement in the training community

www.england.nhs.uk

Yorkshire and the Humber Early Intervention in Psychosis Network

Time for a break?

• 1. Medication & Treatment
• 2. Role of the Care Coordinator
• 3. Developing the therapy workforce
• 4. Service Development & Challenges
• Key Priorities and Actions for Meeting the Standards
• Key Priorities and Actions for Overall Quality

Improvement PLEASE NOTE KEY POINTS ON FLIPCHART – THESE WILL BE COLLATED & SHARED AFTER THE MEETING. Professional Groups Table Top Discussions

www.england.nhs.uk

Any Other Business

• Maastricht Approach
• Date of the Next Meeting: 17th

November

• Future Meeting Planning –

ARMS,CAMHS

• Closing Remarks
• Evaluation

Dr Steve Wright, Co-Chair

www.england.nhs.uk

Yorkshire and the Humber Early Intervention in Psychosis Network

Thank You for Attending!

Don’t forget to fill out your evaluation!