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.

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.

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.

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.

Improving smoking cessation in first episode psychosis: a quality improvement project by the City & Hackney Early and Quick Intervention Psychosis (EQUIP)

Smoking tobacco is a major public health issue and a significant cause of increased mortality. People with a first episode of psychosis are more likely to smoke and the subgroup...

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.

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.

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.

Social inclusion and recovery for young people with first episode psychosis: a London survey of early intervention in psychosis teams and their links with the further education system

This article is an account of an ambitious change management effort across the inter‐organisational divide of health and education. It focused on improving the relationships between staff in health and education sectors, to enable people to work together with a sense of shared purpose and joint vision: to get young people with early psychosis back into education and training, and to keep them there. It involved working on people's mindsets, and discarding long‐held negative expectations of what mental health service users can achieve. The project is based in London.

The experience of working with dual diagnosis in an early intervention in psychosis team

This paper presents the outcomes of a small qualitative study investigating the experience of mental health practitioners working with dual diagnosis in an early intervention in psychosis (EIP) team with a focus on the use of a specifically developed screening tool. Interviews were conducted with mental health professionals who were employed as care co‐ordinators within an EIP team. Grounded theory was adopted as a method for making sense of the data obtained. Six themes that emerged from the data are described: the importance of the cycle of change in treatment planning; service accountability and responsibility; the nature of psychotic illness; assumptions about substance use; confidence; and using the tool as part of the recovery process. These themes were discussed in relation to research surrounding psychosis, substance use and screening methods.Despite identifying the importance of a more integrated method of working with this complex service user group, gaps remain in practice. Modifications to the screening tool are recommended and a need for substance‐use‐specific interventions training for practitioners working within EIP services is identified.

Who should swing the stethoscope? An audit of baseline physical examination and blood monitoring on new patients accepted by an early intervention in psychosis team

It has been established that patients with severe mental illness are at increased risk of physical illness and that physical health screening should be performed when an individual experiences a first episode of psychosis. The aim of the audit was to examine how physical health screening was achieved in the real world of an early intervention in psychosis (EIP) service in Scotland. Of particular interest was considering if primary or secondary care were more effective in providing specific physical health assessment for those presenting to the service. A case note audit was performed. The audit shows that physical examination and blood tests were being completed in the majority of service users under the care of the Esteem service. However, an unacceptably high number were not undergoing sufficient initial screening for metabolic syndrome or having baseline monitoring prior to commencing antipsychotic medication. Our results suggest that relying on primary care to provide physical health screening was not an effective approach in a population experiencing first-episode psychosis. Having a psychiatrist motivated to perform physical health screening within the EIP team may help to improve the uptake of physical health screening. Strategies to improve physical health screening in EIP services are discussed.

Traffic Lights

PurposeThe current risk management system for community mental health patients in England is based around the Care Programme Approach (CPA). This system is not responsive to changes in risk for community patients. This paper aims to introduce a practical system to manage risk that has been developed for an Early Intervention Service in East London on the basis of need.Design/methodology/approachCoding of red, amber and green is associated with specific criteria agreed by all disciplines in the team. The change of a code leads to a rapid change in risk level and management. An agreed clinical and non‐clinical action plan leads to a whole team response. The limitation of use is dependent on the size of the case load and the number of clinical staff attending a daily clinical briefing.FindingsZoning according to the traffic lights system could complement the CPA system and support a clinical governance structure utilising a whole team response.Research limitations/implicationsThe risk management system described has not been tested empirically. Currently it has been used in early intervention mental health teams but will need to be adapted for other teams with bigger case loads.Originality/valueThis practical risk management system is aligned with the statuary CPA requirements. A dynamic and flexible management of risk is central to early intervention in psychosis teams but the risk management system described can suit any community mental health team and fits well with the distributed responsibility model of functionalised teams according to new ways of working.

Training to develop family inclusive routine practice and specialist family interventions in Somerset

Current national policies present a challenge to the existing mental health workforce as most staff have not been trained to work with people within the context of their social support network. This paper presents two complementary training initiatives designed to enable mental health staff to meet the range of needs of families: (1) an in‐house accredited (one‐year) course that has enabled the successful creation of specialist family intervention in psychosis teams; and (2) a whole‐team trust‐wide training programme (three‐day course) to promote partnership working with families by both community and inpatient teams. Issues that have enabled the successful translation of training to practice are considered.