Early Intervention In Psychosis Teams Research Articles

Evaluation of the Early Psychological Intervention Clinic within the Mid-Essex Early Intervention in Psychosis Team

NICE guidelines state that adults experiencing a first episode of psychosis should access psychological input within two weeks of referral (NICE, 2016). In the Mid-Essex Early Intervention Psychosis Team, clients can book up to four sessions of assessment and brief intervention when first referred and feel ready to access the Early Psychological Intervention Clinic (EPIC). Following this, clients can be referred for further psychological intervention should they want or require this. This service evaluation aimed to evaluate the effectiveness of EPIC sessions by comparing the CORE-OM (Evans et al., 2009) outcome measure pre- and post-EPIC and collecting qualitative feedback using a structured interview with open-ended questions. The results showed clinically significant improvements for 45 per cent of clients. Paired T-Tests revealed statistically significant improvement in the overall clinical score and all subsections of the CORE, suggesting EPIC sessions are effective in improving wellbeing, functioning, symptoms and reducing risk. Furthermore, qualitative feedback showed that clients who completed EPIC tended to have good experiences and be motivated to work psychologically. The results of the service evaluation suggest EPIC sessions are beneficial to clients and help improve overall wellbeing, producing clinically and statistically significant outcomes. Clients also reported them being a helpful experience. Therefore, EPIC provides favourable outcomes to the service which suggests it should continue to be offered to clients. Limitations and ideas for service improvement are discussed.

Evaluating social drop-in facilities and their impact on social recovery in early intervention in psychosis services

Purpose“Social recovery” is a long-cited aim within the UK early intervention in psychosis (EIP) services; however, there is a lack of evidence regarding existing social recovery provisions and how these can be improved. This paper aims to evaluate an existing social drop-in facility within an EIP team, ran within the Birmingham and Solihull Mental Health NHS Foundation Trust, and highlight the potential benefits of delivering such services for people diagnosed with first episode psychosis.Design/methodology/approachAttendance and basic demographic statistics (age, gender and ethnicity of attendees) were collected over a period of 13 weeks. In addition, two semi-structured focus groups were conducted: one with EIP staff members (community psychiatric nurses and support workers) and the other with current service users, with both groups describing their satisfaction and experience of the drop-in facility and how it can be improved.FindingsInductive thematic analysis was used to analyse data from both focus groups, with six overarching meta-themes being identified: reflection, environment, emotional experience, recovery, activities and interactions. Service users and staff reflected that the drop-in facility was an asset to the service, although work could be done to improve overall attendance.Originality/valueThis paper explores how a social drop-in facility can provide a supportive, positive environment that aids recovery from psychosis for service users and improves working conditions for the EIP staff.

Achieving Engagement With Services in the Asylum Seeker and Migrant Cohort

AimsOnce refugees and migrants have accessed mental health services, there are a number of potential barriers to establishing a positive therapeutic relationship with clinicians and engaging patients in treatment. WHO recommend that training programmes can help clinicians to understand and assess mental health difficulties according to different cultural explanatory models of psychological symptoms. This audit aims to explore current training of those who work with asylum seekers and migrant patients, within the Merseycare Early Intervention in Psychosis teams.MethodsA survey of 11 questions was sent out to all assessors, team managers, care co-ordinators, psychologists and doctors within the Early Intervention in Psychosis teams. Questions were asked regarding demographics of participants, their views of the difficulties and barriers of working with asylum seekers, their current level of training to work with this particular cohort of patients and their willingness to attend such training.Results33 results were collected and consisted of a broad range of team members. Only 4 out of the 33 participants had any form of training prior to or during their time working with this cohort of patients and 3 of the 4 who had, stated that it was not specific training. Difficulties highlighted included; language barriers, cultural differences, a lack of understanding of the asylum process and a lack of knowledge for local support. All participants said they would be willing to attend training specific to working with the asylum seeker patient population.ConclusionThis audit demonstrates that we are far from reaching the World Health Organisation recommendations of cultural training for all who work with asylum seeker and migrant patients. It also demonstrates a felt need amongst staff for training to be provided. Recommendations from this audit is to consider mandatory training for all staff, including; cultural training, guidance on use of interpreters and awareness of external support agencies.

Anti-NMDA Receptor Encephalitis Associated With an Ovarian Teratoma Presenting as First-episode Psychosis: A Case Report

We report an unusual case of a 27-year-old previously healthy female who presented with a 15-day history of psychotic, cognitive, and unspecified somatic symptoms. She was admitted to the psychiatric ward of an early intervention in psychosis team and medicated with aripiprazole. The young age of onset, the rapid onset, the absent history of psychiatric disease, and the persistence of a marked memory deficit after the psychotic symptoms remitted strongly suggested a nonpsychiatric etiology and led us to hypothesize autoimmune encephalitis as the most probable diagnosis. An investigation was carried out for anti-N-methyl-D-aspartate (anti-NMDA) receptor antibodies in the patient's serum and cerebrospinal fluid, and both tests were positive. The patient was transferred to the neurology ward, where an endovaginal ultrasound showed an ovarian teratoma in her right ovary. She underwent laparoscopic surgery without complications. She was initially treated with intravenous immunoglobulin and methylprednisolone for 5 days, which resulted in marked improvement of her memory and attention performance. Anti-NMDA receptor encephalitis, first described in 2007 by Dalmau and colleagues, is a form of auto-immune encephalitis with prominent neuropsychiatric manifestations, particularly psychotic symptoms. At symptom onset, distinguishing the disease from a primary psychiatric disorder is challenging. This case report highlights the importance of early psychosis treatment teams considering the diagnosis of anti-NMDA receptor encephalitis when evaluating new referrals with a potential diagnosis of first-episode psychosis, particularly when young patients with no relevant personal or familial psychiatric history present with neuropsychiatric symptoms and a distinctive pattern of symptom fluctuation over time.

Early intervention in psychosis team (EIT): pathways to care

AimsThe main aim of this study was to investigate whether the EIT access and waiting time standard (>60% of people experiencing first episode psychosis (FEP) are treated with a NICE-approved care package within two weeks of referral) was being met within Liverpool EIT.We also wanted to understand the pathway to treatment within EIT services, identify delays in the process of triage/assessment/MDT/medical review and implement changes to reduce delays.MethodThis study was a retrospective cross-sectional audit of all patients accepted on to the FEP pathway following MDT discussion in the Liverpool EIT Teams across May and June 2020.Case notes were analysed for delays in referral, engagement with assessment and care-coordinators, as well as prescriber review offering medication. The data were collated and analysed before implementing changes.Result40 patients presented as FEP in May and June 2020, 6 were excluded due to an extended inpatient stay.Within the remaining patient cohort (n = 34), 64.7% of patients were engaged with a care package within 14 days. Only 14.7% of patients received an offer of medication within 14 days, the mean time to be offered medication was 39 days.26% of patients first contact within MerseyCare Trust was with EIT, 74% presented elsewhere. 24% instead presented to liaison psychiatry from A&E departments, 18% to the single point of access team, 9% to criminal justice liaison team (CJLT) and 9% to North West Ambulance Service triage car.29% of referrals came from the community (GP and counselling services), 15% from CRHT (crisis resolution and home treatment team), 14% from CJLT, 12% from urgent care team, 9% from liaison psychiatry.ConclusionThe Access and Waiting time standard was met. However, this study showed that patients were not being referred to EIT at first point of contact. This study shows 26% of service users first presented to liaison psychiatry, yet only 1/3 of those were immediately referred to EIT, the remainder being later referred by other services e.g. CRHT.In addition to referral delays, lack of medical practitioner availability caused significant delays in arranging medical reviews, delaying patients access to medication.The changes implemented to address these issues included educating MerseyCare services in the early recognition of psychosis to increase early referral. Non-medical prescribers’ roles were developed to perform initial medical reviews in addition to doctors, allowing patients earlier medication access. This allowed ‘urgent slots’ to be developed, time set aside for emergencies enabling prompt review of urgent cases.

A retrospective observational study of vitamin D levels in patients within the Tameside and Glossop early intervention in psychosis team

AimsGrowing evidence indicates that Vitamin D deficiency is associated with psychotic symptoms. Although evidence suggesting a causal relationship is limited, theories regarding neuro-inflammatory modulation are promising. Alternatively, deficiency may signify chronic illness or poor functioning. Nevertheless, Vitamin D levels below 50nmol/L increase the risk of osteoporosis, muscle weakness, falls and fractures, thus identification and treatment are important.The association between Vitamin D levels in patients within the Tameside Early Intervention in Psychosis Team (EIT) was studied, hypothesising a strong correlation.MethodThe records of all patients in the EIT as of 01/07/2020, over the age of 16 years old (n = 183), were studied. The first Vitamin D level taken while under the EIT and the CGI scores closest to the date of this level were recorded. Vitamin D levels of 25nmol/L and under were classified as deficient, levels of 25.1 - 50nmol/L were insufficient.Result45.90% (n = 84) of patients did not have their levels recorded. Of the 55% (n = 99) patients who had Vitamin D levels recorded, 49.50% (n = 49) were insufficient and 22.22% (n = 22) were deficient. Therefore, only 28.28% (n = 28) had either optimal or sufficient Vitamin D levels. The majority of Vitamin D levels were taken in Autumn (36.46% n = 36).75.76% (n = 75) of patients had both vitamin D levels and CGI scores recorded, with an average of 35.65 days between date level and score recorded. A weak negative correlation between overall CGI scores and vitamin D level was calculated, producing Spearman R Correlation Coefficient of -0.15.ConclusionAlmost 3/4 of the studied patients being assessed for psychotic symptoms had either insufficient or deficient levels of Vitamin D. The correlation between symptom severity and Vitamin D level was weak however. While we cannot comment on the causality of the relationship, it appears that there is an association between our studied patient group and Vitamin D insufficiency.The evidence to suggest that supplementation can reduce psychotic symptoms is limited however, supplementation can reduce the risk of osteoporosis and falls, therefore would improve patient care. Only 55% of the patients within the EIT had their Vitamin D levels tested. As a result of this study, the authors recommend that all patients in the EIT have their Vitamin D levels tested as part of their psychosis assessment.The study is limited due to low numbers of patients studied and the fact that recorded CGI scores were often recorded at a later date to Vitamin D levels.

Physical health of patients under EIP - a service evaluation

AimsThe aim of the project was to get a baseline of the number of patients who have had blood tests, ECG and physical health observations completed in the past 12 months.MethodThere are 30 patients under Early Intervention in Psychosis team at Bassetlaw Hospital , Nottinghamshire. The elctronic notes and blood reporting system were checked for each of the patients, to get the data on blood test results , ECG reports and Physical health (Blood pressure, heart rate and weight) .ResultIt was noted that 19/30 patients had Blood tests completed, 14/30 had ECG completed and 19/30 had physical health checks completed. All these patients except one were on antipsychotic medications.ConclusionFurther work is still required in getting 100% results for all these different variables. This may include the need to review the process of how we engage the patients for physical healthcare checks. With the inclusion of a physical healthcare worker now, we might be able to improve results. Hence this evaluation would be redone in a years' time.

COVID‐19 and the psychopathology of patients in an EIP service: a case series

Patients with psychosis are a particularly vulnerable group where the widespread, unpredictable changes in the COVID‐19 situation surrounding the pandemic and subsequent lockdown are very likely to have a significant impact. Here, the authors discuss a number of patients who presented to the early intervention in psychosis team and included COVID‐19 in their psychopathology. They also consider the main clinical patterns and management messages.

Evidence base for early intervention in psychosis services in rural areas: A critical review.

Early Intervention in Psychosis teams (EITs) are a growing entity internationally, yet they remain under-researched given challenges facing their delivery. Model adaptations include stand-alone services, a hub-and-spoke model with various bases and integrating specialist staff into existing mental health teams. The present critical review focuses on reviewing the evidence base for the delivery of EITs in rural areas, first pertaining to evidence for model adherence and second to clinically outcomes. A systematic literature search was undertaken, finding 53 papers of interest. Nine papers met the inclusion criteria. A critical appraisal tool was used to consider the quality of the evidence and a narrative review of their findings is presented. The five studies reporting clinical outcomes of rural EITs demonstrate positive outcomes of a hub-and-spoke and stand-alone EIT on reducing hospital admissions, psychotic symptoms and improving quality of life. One study directly comparing hub-and-spoke to stand-alone EIT found that hub-and-spoke EIT had more positive outcomes than a stand-alone service. Of the studies attempting to promote adherence to EIT model in rural areas, services show low overall adherence and report issues pertaining to funding and managerial support for practical barriers to implementation. EIT services in rural areas may show similar positive outcomes to urban areas and adaptations to suit rural populations appear acceptable, such as using a hub-and-spoke model, though further research is required. Adherence to EIT service models in rural areas may be limited and training programmes to promote adherence benefit from managerial and financial support.

Welcoming peer workers in NHS settings: facilitating readiness with an Early Intervention in Psychosis team

Purpose A pilot project commissioned to assess feasibility and impact of peer support in an Early Intervention in Psychosis (EIP) service highlighted the importance of team readiness. The purpose of this paper is to reflect on the lessons learned in recognising and facilitating team readiness in an NHS setting. Design/methodology/approach The literature suggests that mental health teams need to be ready to implement peer support, if this is to be done successfully. The authors describe the process of preparing for peer support, obstacles that arose and ways that the team found to address these. Findings The team had actively sought to develop peer support for some time, and negotiated with Trust managers to agree these roles in principle. However, initially unspoken concerns about duty of care emerged as a key obstacle. An arguably paternalistic desire to protect potential peer worker colleagues from stress and distress could have resulted in unnecessary risk aversion and a narrowing of the role. Willingness and opportunity to reflect on the change in relationship from service user/professionals to colleagues enabled these concerns to be aired, and practical solutions agreed. Practical implications Team enthusiasm is not the same as team readiness. The team’s willingness to identify and reflect on implicit concerns facilitated an acceptance of the change in relationship with peer workers, which in turn enabled the development of standard operating procedures to ensure safe and effective peer support as “business as usual.” Originality/value This paper considers the process of welcoming peer workers in an EIP team and offers practical suggestions that may be of value to other teams seeking to implement peer support in similar adult mental health settings.

Research and practice for ultra-high risk for psychosis: A national survey of early intervention in psychosis services in England.

Evidence from meta-analyses of randomized clinical trials show interventions for young people at ultra-high risk (UHR) of developing psychosis are effective both clinically and economically. While research evidence has begun to be integrated into clinical guidelines, there is a lack of research on the implementation of these guidelines. This paper examines service provision for UHR individuals in accordance with current clinical guidelines within the National Health Service (NHS) in England. A self-report online survey was completed by clinical leaders of early intervention in psychosis (EIP) teams (N = 50) within the NHS across England. Of the 50 EIP teams responding (from 30 NHS trusts), 53% reported inclusion of the UHR group in their service mandate, with age range predominantly 14 to 35 years (81%) and service provided for at least 12 months (53%). Provision of services according to NICE clinical guidelines showed 50% of services offered cognitive behavioural therapy (CBT) for psychosis, and 42% offered family intervention. Contrary to guidelines, 50% of services offered antipsychotic medication. Around half of services provided training in assessment by Comprehensive Assessment of At Risk Mental States, psycho-education, CBT for psychosis, family work and treatment for anxiety and depression. Despite clear evidence for the benefit of early intervention in this population, current provision for UHR within EIP services in England does not match clinical guidelines. While some argue this is due to a lack of allocated funding, it is important to note the similar variable adherence to clinical guidelines in the treatment of people with established schizophrenia.

Research and practice for ultra-high risk for psychosis: A national survey of early intervention in psychosis services in England

ObjectivesEvidence from meta-analyses of randomised clinical trials shows interventions for young people at ultra-high risk (UHR) of developing psychosis are effective both clinically and economically. While research evidence has begun to be integrated into clinical guidelines, there is a lack of research on the implementation of these guidelines. This paper examines service provision for UHR individuals in accordance with current clinical guidelines within the National Health Service (NHS) in England.MethodA self-report online survey was completed by clinical leaders of Early Intervention in Psychosis (EIP) teams (n = 50) within the NHS across the UK.ResultsOf the 50 EIP teams responding (from 30 NHS Trusts), 53% reported inclusion of the UHR group in their service mandate, with age range predominantly 14–5 years (81%) and service provided for at least 12 months (53%). Provision of services according to NICE clinical guidelines showed 50% of services offered cognitive behavioural therapy (CBT) for psychosis, and 42% offered family intervention. Contrary to guidelines, 50% of services offered antipsychotic medication. Around half of services provided training in assessment by CAARMS, psycho-education, CBT for psychosis, family work and treatment for anxiety and depression.ConclusionsDespite clear evidence for the benefit of early intervention in this population, current provision for UHR within EIP services in England does not match clinical guidelines. While some argue this is due to a lack of allocated funding, it is important to note the similar variable adherence to clinical guidelines in the treatment of people with established schizophrenia.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Tracking referrals to early intervention in psychosis team: An audit

AimsTo monitor if the early intervention services (EIS) in Sandwell meet the standard of assessing all patients referred to the team within the set target. To monitor factors that affects the outcome including the source of referral, whether the patients, are known to another team, and the demographic features of the patient.BackgroundProviding timely, appropriate and coordinated care for patients presenting with a first episode of psychosis has been a focus for EIS teams to improve outcomes, experiences and in reducing costs. In April 2016, new target times of 5–10 days for referral-to-assessment and 14 days for referral-to-treatment were introduced by the government.MethodAll the referrals that were made since 01/04/2016 were followed up. A comparison was made with the referral-to-assessment and referral-to-treatment target for referrals made before the 01/04/16.ResultsThere has been an increase in referrals. Preliminary evidence gathered suggests that there has been a marked improvement in the referral-to-assessment pathway and referral-to-management pathway. Patients referred to the EIS are offered an earlier assessment. Majority of the referrals made are however not appropriate to receive care from the EIS, and are not taken on by the team. All the patients that are accepted by the team are offered a NICE treatment package. Most of the referrals that come from other EIS teams or wards, are accepted by the team, at least for an extended assessment. Referrals from Children services are usually at the point when they are due to turn 18, for a second opinion.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

Frequency of change of diagnoses in first‐episode psychosis

Early diagnosis leading to relevant treatment and appropriate psychoeducation is crucial to the role of an early intervention in psychosis (EIP) team. However, diagnostic uncertainty in first‐episode psychosis in young people has to be acknowledged. Here, the authors examine the frequency with which diagnoses of psychotic disorders change between entry and exit from an EIP team and the practical implications for relevant psychoeducation.

Protocol for a multicentre study to assess feasibility, acceptability, effectiveness and direct costs of TRIumPH (Treatment and Recovery In PsycHosis): integrated care pathway for psychosis

IntroductionDuration of untreated psychosis (time between the onset of symptoms and start of treatment) is considered the strongest predictor of symptom severity and outcome. Integrated care pathways that prescribe timeframes...

Discharges from an early intervention in psychosis service: where do patients stand after 3 years?

Continuity of care is an important therapeutic factor in psychiatric services. This study aimed to look at the continuity of care for patients following discharge from an early intervention in psychosis service. Continuity of care was assessed by looking at whether a patient was still with the same service after 3 years or more following discharge from an early intervention in psychosis service. If not, records were checked to see where their care had moved. Discharges from 2006 to 2009 were included in the study. Descriptive statistics were worked out to calculate the proportion of service users who remained with the same service and those who had moved to other services. About 8% of patients had moved to another service during the identified study period. Only 4% of patients had moved from a less intensive to a more intensive service within this time. The findings from this study showed that only a very small proportion of patients discharged from an early intervention in psychosis service move to another service in the 3 years following their discharge. Movement of patients to a more intensive service after discharge from the early intervention in psychosis team was even lower. Most patients thereby have a stable continuity of care following discharge from an early intervention team.

Cannabis use and first-episode psychosis: relationship with manic and psychotic symptoms, and with age at presentation

Cannabis use has been reported to be associated with an earlier onset of symptoms in patients with first-episode psychosis, and a worse outcome in those who continue to take cannabis. In general, studies have concentrated on symptoms of psychosis rather than mania. In this study, using a longitudinal design in a large naturalistic cohort of patients with first-episode psychosis, we investigated the relationship between cannabis use, age of presentation to services, daily functioning, and positive, negative and manic symptoms. Clinical data on 502 patients with first-episode psychosis were collected using the MiData audit database from seven London-based Early Intervention in psychosis teams. Individuals were assessed at two time points--at entry to the service and after 1 year. On each occasion, the Positive and Negative Syndrome Scale, Young Mania Rating Scale and Global Assessment of Functioning Scale disability subscale were rated. At both time points, the use of cannabis and other drugs of abuse in the 6 months preceding each assessment was recorded. Level of cannabis use was associated with a younger age at presentation, and manic symptoms and conceptual disorganization, but not with delusions, hallucinations, negative symptoms or daily functioning. Cannabis users who reduced or stopped their use following contact with services had the greatest improvement in symptoms at 1 year compared with continued users and non-users. Continued users remained more symptomatic than non-users at follow-up. Effective interventions for reducing cannabis use may yield significant health benefits for patients with first-episode psychosis.

Effectiveness of adherence therapy in patients with early psychosis: A mirror image study

In patients with early psychosis, medication non-adherence is associated with more frequent relapse. Observational studies have reported that up to 60% of patients fail to take medication as prescribed. This study aimed to establish the effectiveness of adherence therapy (AT) training for two multidisciplinary early intervention in psychosis (EIIP) teams in preventing relapse in their patients. This intervention involved six 1-day team AT training sessions delivered monthly over a 6-month period. Participants were patients with early psychosis who were on the caseload of the EIIP teams during the study period. A mirror-image design was used, comparing clinician ratings of relapse in the year preceding training (year 0) and the subsequent year (year 1). Results showed that in year 0, the mean number of relapses was 0.96 (standard deviation (SD) = 1.10). During year 1, relapses reduced significantly (P < 0.01) to 0.34 (SD = 0.64). No unexpected effects of training were reported. A thematic analysis of staff views of training, and service users' views of their care received from EIIP teams, was also completed. Challenges in faithfully incorporating AT skills into practice were reported. In conclusion, AT training coincided with reductions in relapse rates in patients receiving services from an EIIP team, but no other changes in outcomes were detected.

Service users' views of moving on from early intervention services for psychosis

Lester et al's paper is timely.1 Many early intervention in psychosis (EIP) teams have been in action for over 3 years and are refining discharge pathways to primary care. This interface is not just with colleagues but now also with commissioners. While there is robust economic evidence for EIP, this perhaps sits outside the regular reading of most GPs.2 This interface needs active management and should not be relied on to grow organically. Every interaction with GPs should name the team and provide opportunity for shared learning, enhanced by the many leaflets covering this area.3 There is a need to help GPs to understand what patients have been experiencing for the proceeding 3 years and not just to advise on subsequent management. In a world of ever changing services it is particularly important that they can be supported to navigate their way back in and EIP teams would tend to maintain responsibility for this, sometimes necessitating a brief period of re-engagement to do so. This is added value from an economically justified team. GPs are often left with a client who is still on medication and are quite reasonably asking for how long they may continue, when medication can be safely stopped, and what the considerations and risks in doing so may be. There is a concern that vocational aspects, that are particularly valued by clients, may be among the hardest to access from primary care.

Service‐users’ experiences of an early intervention in psychosis service: An interpretative phenomenological analysis

Previous research regarding Early Intervention in Psychosis (EIP) services has mainly adopted quantitative methodologies, in order to study the effectiveness of EIP services. Research studies that have explored service-users' experiences of EIP services are small in number. This research aimed to explore service-users' experiences of being in contact with an EIP service, its impact of their experience of psychosis and current life situation. Interpretative Phenomenological Analysis (IPA) was used to conduct an in-depth qualitative study of a small sample of EIP service-users, in order to explore their experiences of being in contact with the service. Flexibly guided interviews were conducted with eight service-users who had been receiving a service from an EIP team for more than 2 years and were recruited using a purposive sampling method. Verbatim interview transcripts were analysed using IPA. Five super-ordinate themes, developed from the analysis, are discussed in sections: Stigma, Relationships, Understanding the experiences, Sense of agency, and Impact on sense of self. Sub-themes of these super-ordinate themes are also discussed. The themes developed from the analysis were envisioned as representing an overarching theme of 'A personal journey of recovery', which was influenced by participants' involvement with the EIP service. Clinical implications include the need for EIP services, as with other mental health services, to find ways to promote recovery and create opportunities for agency and control. Future research directions are also discussed.