Early Intervention in Psychosis Network 7 July 2016 Health/EIP/EIP 2016 0… · • Stephen McGowan, EIP Clinical Lead for Y&H CN and NHSE (North) • Dr Steve Wright, Consultant

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

• [email protected] and [email protected]

• Twitter: @YHSCN_MHDN #yhmentalhealth

• July 2016

Yorkshire and the Humber

Mental Health Network

Early Intervention in Psychosis Network

7th July 2016

mailto:[email protected]

www.england.nhs.uk



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


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


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


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.


Sign off? • Any comments or suggestions prior to sign-off.

• Review in 6 months


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



National and Regional Update

Moggie McGowan, EIP Clinical Lead (Yorkshire & The Humber),

NHS England North

www.england.nhs.uk



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 T HE POINT OF T HIS TALE –

PSYCHIAT R IC DIAGNOSE S….

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?



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:

olanzapine 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)

0 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

0

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

0 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


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….”


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.


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_Competences.pdf

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

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 opportunities 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



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



Thank You for Attending!

Don’t forget to fill out your evaluation!

Documents

Early Intervention in Psychosis Network 7 July 2016 Health/EIP/EIP 2016 0… · • Stephen McGowan, EIP Clinical Lead for Y&H CN and NHSE (North) • Dr Steve Wright, Consultant