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A QUIET EVOLUTION:Early Psychosis Services in British Columbia

A Survey of Hospital and Community Resources

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Tom Ehmann, Ph.D.Provincial Early Psychosis Liaison

November 2004

British Columbia Schizophrenia Society

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contentsAcknowledgements 3Executive Summary 5Introduction 7

Methods 9Time periods 9Materials 9Procedures 9Response Rate 10

Results 11Hospital Survey 11Community Services General Survey 12Training and Development - General Survey Results 15General Survey Conclusions 16Community Survey Part B- Early Psychosis Programs 16Program size and Funding 18Staffing 18Program Components 20Education 22Clinical training 22Program Evaluation 23Research 24Priorities and Planning 24Communities with Programs Compared to Communities without a Program 25

Summary and Discussion 27Limitations of the Survey 32

Conclusions 33

Appendices 35Appendix 1 - Hospital Survey by Hospital 37Appendix 2 – Hospital Survey by Hospital (continued) 38Appendix 3 - Priorities, Plans and Obstacles of Programs 39

References 41

AttachmentsHospital Services Survey 43Outpatient Services Survey 45

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T his work was undertaken under the auspices of the British Columbia Schizophrenia Society (BCSS). Funds allowing the BCSS to further early

psychosis awareness in the province via development of an Early Psychosis Liaison position was provided by an unconditional grant by Eli-Lilly. We thank Eli-Lilly for this vital contribution to assist dissemination of best practices information and foster programmatic improvements in BC.

Many thanks are due to the busy clinicians and managers who kindly took the time to examine the services their facilities were providing and to share that information with the author. It is not an easy task to divulge the potential problems within a service. The candor and integrity of respondents to this survey is appreciated enormously.

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S urveys aimed at assessing the state of service delivery in British Columbia were distributed to hospitals and community services. The analyses were based on eleven hospitals and

23 communities. Twelve communities indicated that they operated a specialized early psychosis program.

Roughly half of the hospitals indicated they used various treatment protocols specific to early psychosis, that staff training had occurred and that interface with community resources was adequate. Only half of hospitals indicate that their ability to treat first episode cases had improved in the past few years despite access to information concerning best practices. These results suggest that there is considerable room for improvement in the inpatient practices surrounding early psychosis cases.

A general survey of community services revealed not only the common concerns of time and resource constraints but a number of encouraging patterns of practice. Overall ratings of accessibility and clinician skill were good. Most sites indicated that appropriate fundamental medical and psychosocial services were being provided. Participation in outcome assessment was performed in only about half of settings.

The twelve programs operating in the province were more closely examined in a separate survey. The programs varied immensely in the staffing, approach and comprehensiveness of the services they provided. Training and skill levels of clinicians were found to be reasonably good but several obvious deficiencies appear to exist. Outcome evaluation, program evaluation and research activity varied, with only some programs attaining a high degree of participation. Comparisons between areas with programs and those without favoured programs on all but one of the indicators employed in the survey.

The analyses prompted some reflection on the successes and shortcomings of the various programs and their approaches. Central to the discussion were the issues of treatment fidelity to best practices and accountability. Simply put, saying that one is providing services to early psychosis cases does not necessarily mean that best practices are being followed and that desired outcomes are being achieved. The commitment to evidence based practice must be realized both through support from all levels of administration through and personnel demonstrating adherence to best practices and program evaluation.

It appears that the advancement of services has been evolutionary rather than revolutionary across the province. Many competent and committed individuals deserve tribute for their efforts to advance the principles and practices of early psychosis intervention. Despite the positive strides attained to date, greater support in the quest to produce optimal outcomes is needed if the benefits of intensive intervention for this population are to be realized.

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T he development of services in British Columbia that attempt to provide optimal care for those experiencing psychosis for the first time received a huge boost

beginning in 1999. The Early Psychosis Initiative (EPI), an inter-ministry project, furthered the early intervention paradigm through a series of educational and training components and the establishment of several demonstration projects. A set of guidelines outlining the best available practices was published in 2002 (1). The EPI formally ended with the publication of those guidelines. However, the concepts and enthusiasm for early intervention in psychotic disorders continued to flourish in BC. The evolution of services that specifically consider the needs of patients and their families at the earlier phases of a psychotic disorder has continued in the past few years. Unfortunately, the end of EPI complicated communication across regions of the province. Changes in the Ministries of Health and the Ministry of Children and Family Development included shifts to greater local control of service delivery development. EPI, with its role as a central coordinating body, was superceded by advances being made at more local levels.

The BCSS, funded by an unconditional grant from Eli-Lilly, sought to continue some aspects of the role that EPI provided, namely, acting as an advocate for the dissemination of evidence-based practices in early psychosis and facilitating development of appropriate services across BC. A part-time position (“provincial liaison”) was created that attempted to act as a central resource, inform diverse areas of BC about new developments in the field and foster the encouraging strides made in BC. The diversity of services available for those affected by recent onset psychosis has not been documented. A set of surveys was constructed to capture the current state of care delivery across BC, document current practices and assist practitioners and planners by providing information about the type and extent of service delivery efforts.

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During the course of the survey period several very exciting developments occurred. Perhaps the most important included the release by the Ministry for Child and Family Development (MCFD) of Canada’s first mental health plan specifically concerned with children and youth (2). The importance of early intervention in psychosis was stressed in that document and the MCFD has been making significant progress in ensuring that appropriate services with trained practitioners are available to young people and their families. Other important developments included the establishment of increased research capacity (with funding coming from both private and public sources), continuing professional development of clinician practitioners and the further entrenchment of the early intervention approach in the planning priorities of administrators and managers.

The current report represents a snapshot of diverse settings across BC in 2003-2004. Services are constantly changing so it is inevitable that deficiencies exist

in this report concerning both the breadth and scope of services. The goal of the survey was not to provide a comprehensive listing of every existing service for early psychosis clients. Rather, it was intended to serve as a reference point that would allow comparisons to be made across different geographical regions and over time. It was hoped that some modest data could be compiled relevant to the models of providing care that are used, comprehensiveness of services, staffing type and amount, funding arrangements, case load sizes and activities concerning research, education, training and quality assurance.

A final note on terminology is in order. The terms “early psychosis” (EP) and “first episode” (FE) are not necessarily synonymous. Early psychosis is a broader term that can be defined widely but generally refers to the first several years after the onset of psychosis. It does not refer to an early age of onset. It is very possible for a person to have several distinct episodes of a psychotic disorder within these first

few years. Whereas every FE case is an “early psychosis” case, not every early psychosis case may be in a first episode. In some instances, the survey asked specifically about FE practices since it was believed this would provide greater contrast and most accurately reflect the differences when compared to services provided to those with long established illness.

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“Services are constantly changing

so it is inevitable that deficiencies

exist in this report concerning both the breadth and scope

of services.”

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Time periods

This report is based on information collected between 2003-2004. Development of the surveys occurred in early to mid-2003. Most respondents completed the surveys in mid-late 2003. Several services submitted completed surveys in mid-2004. Analyses were completed by September 2004.

Materials

Three surveys were constructed. The questions developed for each survey were essentially best practice indicators or descriptive in nature. The first survey addressed inpatient care (see attachment at end of document). The second survey was sent to community care services such as mental health teams (see attachment Part A). The third survey, labeled Part B, was an extension of the Community survey. It requested much more detailed information if the respondent indicated that specialized early psychosis services were provided in that center. This set of questions sought to capture the nature of what might be termed “EPI Programs”.

Procedures

A list of inpatient and outpatient settings was created. For inpatient facilities, a listing of all hospitals in the province with psychiatric beds was obtained. Smaller hospitals with no designated psychiatry beds and specialized hospitals such as geriatric or rehabilitation facilities were excluded. A decision was made to ensure that all geographic areas were included. The community services list was generated by first referencing the list generated by a series of announcements regarding the creation of the Liaison position that was widely distributed to potentially interested parties across the province. This list initially included all members of the original EPI, which included representation in each of the health regions from persons representing both adult and child and youth mental health systems. Phone calls and subsequent emails widened the potential number of parties

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who expressed interest in being involved in any way with early psychosis initiatives in the province. New names were gleaned from the responses to the earlier inquiries. The final list was then organized by health region. Further inquiries were made asking individuals if they would be willing to complete the surveys. Names were eventually identified for almost all Child and Youth and Adult mental health services in the province. The MCFD Mental Health Professional Advisory Committee assisted solicitation of relevant Child and Youth Mental Health respondents. On Vancouver Island two hubs were established and the

participants kindly circulated surveys at early psychosis meetings that involved all identified communities.

Surveys were circulated to all identified centers by computer. Some respondents requested and received faxed or mailed versions of hard copies. Identified survey participants were sent reminders if they had not returned the surveys within several months. This process went through several iterations. Additional reminders were sent in May 2004.

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A total of 57 community services surveys representing 50 sites were distributed. Twenty-three sites returned surveys for a response rate of 46% (of sites). Twenty-seven were sent to inpatient facilities representing 25 sites. Thirteen inpatient surveys representing 12 sites were returned for a response rate of 48% (of sites). Twelve community respondents indicated they were operating specialized programs for early psychosis.

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Hospital Survey

Responses were obtained from 13 hospitals across BC ranging from small community hospitals to large urban hospitals. No hospitals from the Interior Health Authority replied. One hospital sent in two separate completed surveys. Only one was used in the analysis. Unfortunately, one file was corrupted and the data was lost (CAPE Unit at BC Children’s Hospital). Therefore, the analysis is based on the following 11 hospitals.

Participating Hospitals:Central Island - Ladysmith/DuncanDawson CreekPeace ArchRichmond Royal Jubilee (Victoria)Port Alberni (Vancouver Island)

St. Joseph’s (Comox)St. Paul’s Hospital (Vancouver)Surrey MemorialUBC (Vancouver)Vancouver General

Table 1 reveals that hospital respondents generally endorsed having been helped to better care for first episode cases as a result of the Early Psychosis Initiative and that staff had received copies of the Care Guide. However, simply making available best practices documents did not necessarily translate into better service provision. Most sites who indicated they had not improved had made the Guide available to staff.

Staff training specific to early psychosis had been conducted in more than half of hospitals. Not surprisingly, those hospitals that did provide training also reported a greater tendency to employ protocols such as providing family education and having community care providers begin working with patients before discharge. This suggests that effective change in the way inpatient units provide care is not simply a function of committed individuals but reflects broader organizational commitment. It was somewhat surprising that less than half the sites reported improved ability to service first episode cases over the previous several years. The smaller percentage of sites reporting specific First Episode (FE) protocols for physicians and training to ER staff might relate to respondents’ noting that improved care for these cases has been lagging. The relationship between perceived lack of progress in treating FE patients and lack of non-ER protocols and lack of training to ER staff was statistically significant (p<.05). Most hospitals had no system in place that specifically tracked FE cases.

Only four hospitals responded to the request for a description of the largest obstacles to treating first episode cases. A lack of stepdown beds and the observation that the unsuitability of regular ward settings for these cases were noteworthy comments.

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Three hospitals stated that improved communication with community agencies was their greatest advance in the past year. Closer links to C&Y services and increased ability to refer to specialized early psychosis services in the community were examples of improved community care/hospital liaison. Two hospitals stated they had not made any advances in the past year. Detailed responses for individual sites are contained in Appendices 1 and 2.

Each hospital was asked to describe its highest priorities in more effectively handling first episode cases. Three respondents commented on the need for specialized beds for first episode clients - either in the form of non-hospital residential-type beds, or specially allotted beds for this population. Other comments stated the need for psychological assessments in hospital, the need for better links with the community, and better treatment and assessment protocols. One facility, Vancouver

General, noted that they required a better understanding of the needs of first episode patients since they had not discerned differences between the needs of first-episode versus multi-episode patients.

Community Services General Survey

The community survey consisted of two parts. Part A, the general survey, was intended to capture information on services provided to persons with early psychosis whether the service had a specialized program or saw clients within a more generic setting. Part B was reserved for those who stated they operated an early psychosis program. Population catchment areas ranged from 17,000 to 600,000 with several more specialized subpopulations also being represented (e.g. university students at UNBC and a service for clients on Vancouver Island who have mental retardation). Twelve

indicated they operated an early psychosis program. Vancouver C&Y Mental Health Services directed the survey to Hamber House as an indication of their EPI program.

Respondents to General Survey. Those not operating an early psychosis intervention program have an asterisk:

*Bulkley Valley - North*Campbell River – Vancouver Island*Chilliwack Fraser East - FraserDuncan – Vancouver Island CentralFraser North – FraserFraser South – FraserHamber House – Child and Youth – Vancouver CoastalKamloops – InteriorKelowna – Interior*Liaird Northeast - North*Nanaimo Child and Youth– Vancouver IslandNorth Shore Child and Adolescent Program– Vancouver Coastal *Port Alberni – Vancouver Island Central

TABLE 1 - HOSPITAL SURVEY RESPONSES

Yes (%) No (%) Missing (%) UnsureAre separate statistics kept for 1st episode (FE) clients 27 73Do staff get special training in FE psychosis 55 45Are there specific FE protocols for non-ER medical staff 36 64Are there specific FE protocols for non-physician staff 55 45Are there specialized FE services ( e.g. groups, specialized assessments)

55 45

Are there family education/support protocols specifically for FE cases 45 27 27Are there distinct discharge protocols for FE cases 64 36Are there distinct community services to which you refer these cases for post hospital care

73 27

Is it policy that clients seen by community before discharge 55 45ER staff receive training specifically in FE 36 64BC EPI (1999-2001) helped with caring for FE cases 82 9 9Staff have “Early Psychosis Care Guide” 73 18 9Ability to treat FE improved in past 3 years 45 45 9

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Queen Alexandra Outpatient Services – Victoria - Vancouver Island *Richmond – Vancouver Coastal*Sea to Sky - Vancouver CoastalTerrace – North*University of Northern BC Student Counseling ServicesVancouver – Vancouver Coastal*Vancouver - Child and Youth Mental Health Services *Vancouver Island Mental Health Support Team (IQ<70) - Vancouver

IslandVernon - InteriorVictoria - Vancouver Island SouthTwenty- three surveys were returned. One service was duplicated and only Part A was obtained for one area. Therefore, the general community services analysis is based on 21 services. The response rates for individual questions varied from 19-21 for questions that required a Yes or No answer. The percentages listed

represent a proportion of the valid cases unless stated otherwise.

Table 2 shows that 81% of respondents stated there were specially designated early psychosis services in their area. Six (32%) sites were identified as exclusively adult oriented services and three (16%) were exclusively C&Y oriented. The majority (53%) included both adults and C&Y into their services. Most

TABLE 2 - GENERAL SURVEY RESULTS FOR SERVICE COMPONENETS AND STRUCTURE

Yes (%) No (%) Unsure (%) Missing (%)Do you have a functioning Early Psychosis (EP) Steering Committee

76 24

Are there services specifically designated as “Early Psychosis” or First Episode”

81 19

Are there staff designated as having special competence and who handle most EP cases

67 29 5

Are EP clients simply seen as part of larger/routine services 38 57 5Did the BC EPI from 1999-2001 positively influence your handling of FE cases

76 14 5 5

Have staff received copies of the 2002 EPI-produced “Early Psychosis Care guide”

86 10 5

Have there been training events for clinicians in past year 62 38Are public education activities ongoing 52 43 5Do you measure outcomes for each patient 48 43 9Are referral pathways clear and easy to use 57 33 9Is there one central intake number to call 76 24Is ensuring continuity of care a problem 76 14 9

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respondents affirmed the existence of a functioning EP planning committee. Surprisingly, two respondents that served both adults and youth reported no committee in their area.

As expected, the numbers of early psychosis clients seen varied considerably. Five respondents stated they were unsure how many clients were seen in the past year. Of those who endorsed having specifically designated early psychosis (EP) services, nine defined EP as a first episode of psychosis with any duration of previous treatment. Four others defined early psychosis as any episode but occurring within the first five years after onset. The final four used differing definitions such as “any episode to age 19” and “wide range from suspected prodrome to first break”.

Almost all surveys indicated that a broad range of interventions

and other services were offered. Pharmacotherapy, case management and education for families and clients were virtually universal. Group sessions were available in many locations while the availability of training and rehabilitation was more limited. Several centres noted the availability of specialized housing as a particularly noteworthy feature.

Outcomes were measured for each client in about half of settings. There was no significant statistical association between the presence of outcome measurement and any variable in part A of the survey. A second analysis that examined whether the presence of outcome measurement was associated with having program status was also not significant. That is, there was no relationship between having a program and measuring individual outcomes for each client.

Tables 3-7 show respondents’ ratings

concerning the expertise available and accessibility of settings.

Respondents rated clinician expertise favorably with over 55% rating competence as “good” and a further 19% rated staff as “excellent”. The largest program noted that staff skills pertaining to working with early psychosis cases varied considerably. Ratings of physician expertise were similar to those for clinicians.

Only 6% of respondents rated clinicians as having excellent time allocation to do early psychosis work (see Table 8). A statistically significant relationship was found between greater allotted time and the designation of staff as having specialized expertise in early psychosis (χ2 = 8.28; p<.05). A trend was also found for greater allocation if the site reported that they operated an early psychosis program. No associations were found between allotted time and other variables in the general survey.

TABLE 3: RATINGS OF ACCESSIBILITY

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TABLE 4: TIME TO FIRST FACE TO FACE ASSESSMENT

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Table 3 - n=20Excellent = easy to find, single point of entry, self-referrals acceptedGood = between excellent and moderateModerate = several entry points, restrictive referral criteriaFair = between moderate and poorPoor = multiple steps to entry, confusing to find services, very restrictive intake criteria

TABLE 5: AVERAGE WAIT FOR MAJORITY OF CLIENTSFROM ASSESMENT TO

TREATMENT START

50

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Continuity of care was identified by 84% of responding sites as a significant obstacle in providing service. Multiple causes of poor continuity were endorsed including: client improvement and wishes to discontinue, dropout, and failure of staff to provide sufficient intensity of contact to properly engage clients. The interplay among these was illustrated by a reference to the problems arising from administrative policies regarding closing files. It was noted that policies to close files for concurrent substance abuse or because of missed appointments led to premature termination of care. One site mentioned that a gap frequently occurred between an inpatient stay and commencement of community care.

TABLE 6: RATING OF CLINICIAN’S SKILL LEVELWITH EARLY PSYCHOSIS

PATIENTS

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TABLE 7: RATINGS OF PHYSICIAN’S SKILLS

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TABLE 8: RATINGS OF TIME ALLOTTED FOR CLINICIANS

TO DO EARLY PSYCHOSIS WORK

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Training and Development - General Survey Results

Only 62% of sites confirmed that staff had attended clinical training events on early psychosis in the previous year. Seventy-six percent believed that the provincial EPI that ended in 2001 had positively influenced their handling of early psychosis clients while 14% stated it had been of no benefit. About 90% of respondents indicated that staff had received copies of “Early Psychosis: A Care Guide”, the 2002 outline of best practices. Public education initiatives were ongoing in about half of sites. The likelihood that public education was being undertaken was associated with the existence of designated specialized services (χ2 = 5.87- p=.05) or specialized staff (χ2 = 5.66- <.06). Conversely, sites where early psychosis patients were seen as a part of routine services

were less likely to deliver education to the public. Less public education was also statistically related to longer average waiting times between assessment to treatment (χ2 = 24.11, p<.005) and to ratings of poorer physician skill (χ2 = 13.28, p<.05). Education to the public was not related to the existence of an early psychosis program, the presence of a planning committee, time allocated to do early psychosis work or any other variables found in Part A of the survey.

Sites were asked to describe their greatest needs, challenges, advances to date, and areas needing most assistance. The most common themes under greatest need to further early psychosis services included: staff training and staff recruitment (in particular, three respondents noted a lack of psychiatrists and psychologists), expanded public education, and greater cooperation across service providers. No consistent themes emerged from

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the question concerning greatest advances. Several respondents noted that simply getting any more specialized services developed was a major accomplishment while several others commented on improved relationships with other government agencies. The development of day programs or specialized housing were also cited as special accomplishments. About 30% of sites said lack of staff was their greatest obstacle – again a lack of psychiatrist involvement or availability was mentioned several times. The other main obstacle identified was lack of funding dedicated to early psychosis intervention. The above themes were repeated when sites stated that they needed assistance with funding and staffing. Also, issues of managerial support and leadership, opportunity to engage in program development and other administrative and organization issues were mentioned in this section.

General Survey Conclusions

It appears safe to conclude that services for early psychosis have evolved in the past five years. Most sites reported they had received education in best practices and that they had been influenced by earlier province-wide activities. Ratings of accessibility and staff expertise appear encouraging. The allotment of time for clinical work to be done was rated as moderate, rather than good or excellent. This suggests that most respondents perceive there is considerable room for improvement in how much time clinicians can devote to early intervention. Continuity of care was also identified as a concern but the nature of the perceived problems was not well elucidated by the survey. For example, the obvious question of transition protocols between C&Y and adult services was not singled out as a concern. Public education was found to be occurring in fewer areas than would be anticipated. Education was associated with reports of specialized services

or designated staff but not with the presence of early psychosis planning committees. The role of administrative support will be discussed in more detail later in this report. Finally, the majority of services surveyed did not carry out measurement of outcomes.

Community Survey Part B- Early Psychosis Programs

Twelve programs are represented in this section. It is believed these constitute almost all programs currently operating in British Columbia. One known exception is a solitary clinician who assists service providers to provide best care across the west Kootenays. Because of the delay between the initial surveys being completed and the analyses, there may be new developments that have augmented the scope and depth of some of these services.

Table 9 shows the inception dates of the programs and lists several admission criteria. Most programs accepted self-referrals. Self-referral

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TABLE 9 – PROGRAM SURVEY RESULTS – BASIC PARAMETERS

Start DateSelf/family Referrals allowed

Predominant Population

ServedDuncan 7/2000 Unclear AdultFraser North 9/2002 Yes BothFraser South 5/2000 Yes BothKamloops 2/2003 Yes BothKelowna 6/2001 Yes BothTerrace 9/2001 No AdultNorth Shore C&Y 8/2002 Yes BothVancouver 5/2000 Yes BothVancouver C&Y (Hamber House)

Missing No C&Y

Vernon 11/2002 No AdultVictoria (Queen Alexandra)

2/2003 Unclear C&Y

Victoria 1996 Yes Both

was used as an indicator of program accessibility. Eight programs have a written mission statement and two more indicated one was in progress.

Criteria for entry into programs varied considerably. Age restrictions, suitability for specialized program elements, and diagnostic status accounted for most of the variations. Responses to the question of allowable length of psychosis for entry into a program revealed that 50% of respondent sites accepted first episode cases while other programs accepted clients in any episode but within several years of first presentation. The latter might best be described as “recent onset” rather than “first episode” programs. All programs indicated that they accepted non-affective psychosis cases, and all accepted co-morbid conditions. Ten of twelve stated that inpatient activities were clearly integrated with their community-based program (the exceptions were Terrace and Vancouver).

The question “length of time before EP client is seen before transfer to regular care” produced only partially

informative data. Five sites (Duncan, Fraser South, Kelowna, Vernon and Vancouver) reported a range of 1-3 years that clients could remain in the program before transfer. One program (Kamloops) had not yet established policy and one program (Victoria) sees clients for up to 5 years. One site reported a very brief length of only three months (North Fraser). Four sites stated that length

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“varies” with qualifiers including: “until client reaches age 19”, “until appropriate services are found” and “depending on mental health status of client”. Similarly, many programs did not appear to have discharge criteria for their programs as only 8/12 sites answered the question. Of those 8, three stated they had no discharge criteria and a further three cited clinical stability.

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TABLE 10 - EARLY PSYCHOSIS PROGRAMS – REFERRALS AND CASELOADS

Ages served

Catchment area pop

Referrals past year

Accepted past year

Current case load

Kelowna 13-25 150,000 22 20 29Vernon 19-25 64,000 28 17 17Kamloops 17-30 120,000 - - 25-30North Shore C&Y 13-27 172,000 - 45 7Vancouver C&Y (Hamber House) 13- 19 As Vancouver 22 17 30Vancouver 13-35 700,000 153 51 20Victoria 15+ 330,000 126 87 130Victoria (Queen Alexandra) To age 19 330,000 30 30 13Central Island (Duncan) 17-30 70,000 20 16 22Terrace 19-30 - 10 7 7Fraser South 13-35 575,000 184 120 163Fraser North 13-30 500,000 150 80 20

Program size and Funding

All services listed, except two, appeared to be primarily funded by regional health authorities. The first exception is the service provided by Hamber House which, as part of Vancouver Child and Youth Mental Health, receives funding via MCFD. The Fraser South Program receives funding from multiple sources. Both Adult and C&Y clinicians operate within the program and are funded by either MCFD or the Health Authority. Most members of the Fraser South Central Team are employees of the Health Authority with at least one FTE provided by MCFD. The research team is self-funded from grants from a variety of sources including government and the private sector with office space and basic equipment supplied by the health authority.

The survey did not capture the role of MCFD funding in shared arrangements such as the Kelowna and Vancouver Coastal North Shore programs. A number of programs indicated that they serviced youth but it was unclear how funding was allocated. It appears that in some instances the program consists of a central coordinator working alongside clinicians in either adult or C&Y teams who would normally be seeing those clients.

Program size data are shown in Table 10. The numbers of clients entering a program varied from a low of 7 per year to a high of 120. As expected, the size of the population in the catchment area correlated significantly with the number of referrals accepted into a program (r = .71, p,.05). The lack of a significant correlation between catchment population and number of referrals (r = .39) might be explained by high numbers of referrals in some locations that do not fit program

criteria. The number of standing cases was essentially uncorrelated to catchment area population size (r = .08,ns). This finding was thought to perhaps reflect the fact that some programs only see clients for a very brief time. However when first Fraser South and then Vancouver were deleted from later analyses, the correlation remained nonsignificant (r =.14). The lack of a significant correlation between current case load and number accepted in the previous year (r = 44) validates the impression gained from viewing the table on referrals that a number of programs are discharging clients in a short period. Unfortunately, the survey did not specifically inquire about the average number of sessions clients are seen.

Staffing

Staffing levels are shown in Table 11. From the table it appears the most well resourced programs are the Fraser South and Victoria programs.

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TABLE 11 - EARLY PSYCHOSIS PROGRAMS – STAFFING

Staffing In FTEs Other PersonnelDuncan 0.5 case manager/coordinator

0.5 case manager0.1 psychiatrist0.2 OT

Fraser North 0.3 psychiatrist2.0 clinicians0.5 clerical0.5 psychologist

Community MHT clinicians provide ongoing case management

See comment below staffing

Fraser South Central Team (Gov. funded)0.2 psychiatrist1 director (Psychologist)1 Intake clinician (SW)1 Group/family therapist (SW)1 Educator (nurse)0.5 clerical

Case managers/clinicians from each Adult and C&Y MHT in each community in the South Fraser – all P/T carrying EPI cases

Funded by non-ministry monies:

2 psychologists1 psychometrist1 research assistant1 genetic counselor

Kamloops North Shore C&Y

1 Nurse1 Life Skills Worker0.5 OT

Kelowna* 1 FT case manager/coordinator (Nursing)? FTE Psychiatrist

Consultation available from: psychologist, OT

Terrace ? FTE clinician (Nursing) – i.e. as needed? FTE 1 psychiatrist– i.e. as needed

North Shore C&Y 0.5 clinicianVancouver 1 Coordinator (Nursing)

0.5 C&Y (SW)1 clinicianapprox .7 FTE from two psychiatrists

Vancouver C&Y (Hamber House)

0.5 family therapist0.5 psychologist0.5 OT0.2 psychiatrist1 clerical1 coordinatorteacher support ad hoc?

Vernon 1 coordinator/clinician (Nursing)0.8 clinician (SW)

Victoria (Queen Alexandra)

1 clinician (Nursing)0.4 clinician (SW)0.1 Psychiatrist

Victoria 7 case managers (SW and Nursing)1 Coordinator1 Psychiatrist

* - It is known that Kelowna also has 1 FTE clinician/case manager for C&Y MH

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TABLE 12 - EARLY PSYCHOSIS PROGRAMS - COMPONENTS AND INTERVENTIONS

CBT WrittenTreatmentProtocols

Phase Specific

Approach

“At Risk” Clients Treated

“At Risk” Ever Given

Anti-Psychotics

Dual- DX*Clients – Referor Integrated

Kelowna Yes Yes Yes Yes No IntegratedVernon No No Yes Yes No BothKamloops No No No No No ReferNorth Shore C&Y No Yes Yes Yes No IntegratedVancouver C&Y (Hamber House)

Yes No No Yes Yes Refer

Vancouver No No No Yes No BothVictoria Yes Yes Yes Yes Yes BothVictoria (Queen Alexandra)

No Yes No Yes No unclear

Central Island (Duncan)

Yes Yes Yes Yes No unclear

Terrace Yes No No No Missing ReferFraser South No Yes Yes Yes No BothFraser North Yes Yes No Yes Yes Refer

* The survey asked if clients are referred to A&D programs, or if the program provides integrated treatment

Program Components11/12 sites employed outreach assessment procedures and the same number stated they engaged in outreach treatment. Although the term “outreach” was not defined in the survey, it is assumed that this refers to the practice of leaving the office/clinic and engaging in treatment or assessment at a location convenient

or comfortable to the client (e.g. a home).

The case management model used varied across programs. Intensive case management with direct service provision of interventions and/or assertive case management were employed by Fraser South, Fraser North, Victoria, Kamloops, Vernon, Kelowna, Terrace and the Queen Alexandra Centre (South Island).

It was unclear what models were employed in Duncan and the North Shore programs. Other programs stated that the model varied according to family need (e.g. Hamber house). Several sites also brokered for other services. Vancouver exclusively employed a brokerage model. However, it is unclear whether Vancouver has moved to more direct service with the added 1.5 FTE positions that occurred about when

....... .. ...... ... .

21

the survey was completed.

• All programs offered the following services:

Medication management Education to clients and families

All except one also offered group interventions. Several programs offered groups to parents and families as well as to clients. Pairing with a voluntary sector organization such as BCSS or CMHA was an approach utilized by several sites. Hamber House noted that it customizes the content of groups to the needs of the particular client population at any given time. Other respondents also noted flexibility in topics offered.

• Topics of groups typically included:

Education about psychosis Stress management Peer and/or family support

• Other programs offered such diverse topics as:

Social skills/socialization (Hamber House, Fraser South)Recreation and fitness (Kamloops, Hamber House)

Thinking skills/cognition (Victoria, Fraser North)Music/art therapy (Victoria)Relapse prevention, substance use and psychosis, how to motivate your child, having fun (Fraser South)

Social interventions given individually such as stress management, problem solving and symptom management were offered by all programs.

Table 12 reveals that written treatment protocols were employed in seven of the twelve programs. Table 12 also shows some surprising results. First, six sites stated they engaged in Cognitive Behavior Therapy (CBT) for psychosis. This unexpected finding suggests that staff at these programs has secured a level of training generally unavailable in BC. CBT training was almost exclusively the domain of graduate programs in Psychology although recent years have seen expansion of training to other professionals. Currently, most CBT training is limited in non-psychology settings to the provision of basic theory and techniques with applicability to mood problems and some anxiety disorders. CBT

for psychosis is a highly skilled application that, to the author’s knowledge, is limited to a handful of practitioners in the province. Second, only half the programs explicitly follow a phase specific approach to illness. The phase specific approach is generally considered fundamental to early intervention in psychosis as it stipulates that the disorder consists of specific stages of recovery with the appropriateness of differing interventions dependent upon the stage experienced by a client. Third, 10/12 programs accepted clients to be “at risk” or possibly in the prodromal phase of a psychotic disorder. The surprise was that three programs treat at least some of their at-risk clients with antipsychotic medications.

Another interesting result concerns how programs are dealing with comorbid substance abuse. Only Kelowna and North Shore stated they had integrated care for psychosis and comorbid dual diagnosis clients. Vernon, Vancouver, Victoria and Fraser South also appeared to be providing treatment for substance abuse to dual diagnosis clients.

......... ......... .......... ......... .

22

TABLE 13 - EARLY PSYCHOSIS PROGRAMS - EDUCATION

Is Public Education Activity Ongoing?Kelowna Yes – schools, health professionals, other gatekeepersVernon Yes – schools, Rotary ClubKamloops Yes – schools, radio/press coverageNorth Shore C&Y Yes - gatekeepersVancouver C&Y (Hamber House) NoVancouver Yes – extensive – web, public ad campaign, schools, gatekeepers, health

professional early psychosis roundsVictoria Yes – schools, yearly conferenceVictoria (Queen Alexandra) Yes - schoolsCentral Island (Duncan) Yes- schoolsTerrace NoFraser North Yes- schools, gatekeepers, community service groupsFraser South Yes –extensive - web, schools, public ad campaign, health professionals,

gatekeepers, yearly conference

Education

Most programs undertook education to public service groups, schools, gatekeepers and the other professionals (Table 13). Many also noted that they engaged in partnership presentations (e.g. BCSS). Perhaps the most extensive educational efforts were undertaken by Vancouver and Fraser South as both had web sites and large

public education campaigns (i.e. posters, bus stop ads etc.) This type of activity, when coupled with gatekeeper training, increases the probability of greater case finding.

Clinical training

The survey question on clinical training appears to have been interpreted by several sites as referring to public education.

Therefore, this item was not analyzed extensively. Several sites did indicate the numbers of events that early psychosis staff attended to learn about early psychosis theory and intervention. Four programs stated there had been no clinical training done in the past year and one program responded with uncertainty whether staff had received any clinical training.

....... .. ...... ... .

23

Program Evaluation

Program evaluation is an extremely important element of any health care delivery system. Without assessment of the processes and outcomes of care it is unknown whether a service is achieving its intended goals.

The evaluation of individual outcomes is essential. In the past, most practitioners made clinical judgments as to the progress a particular client was making along the recovery trajectory. A greater emphasis on the use of more objective outcome indicators has occurred in recent years. Objective indicators can range from simple molar measures such as work or school attendance to more sophisticated micro level instruments such as standardized symptom rating scales. Although a discussion of the importance of reliability, validity and other psychometric concerns is beyond the scope of this report, it must be emphasized that great care must be taken to ensure that whatever data is collected is of high quality.

Seven of the programs routinely measured outcomes for each patient. Some used fairly simple measures

(Terrace, Fraser North, Queen Alexandra, Duncan), while others used sophisticated comprehensive instruments (Hamber, Fraser South). Kelowna, which uses a combination of repeated neurocognitive testing, rehospitalization rates per year, substance abuse and functional role status but does not employ any symptom measures, represents a good approach for a smaller program. Fraser South embeds a comprehensive battery of assessments within a carepath (a binder of documents containing assessments and treatment components within a phase specific format that serves charting, care planning and quality assurance functions).

The use of outcome measures was significantly related to a program’s use of some form of method to help ensure treatment fidelity (χ2 = 6.29, p<.05). It was not related to the provision of CBT, having a mission statement, case load size, number of referrals, catchment population size or the use of a phase specific approach.

Satisfaction surveys provide a legitimate portal into the perceptions of the service by consumers. Only

three of the twelve programs utilized client satisfaction questionnaires (Fraser South, Victoria and Duncan) while a fourth, Fraser North uses them for groups only.

The survey examined whether a program used any measures of program accountability (i.e. measures of adherence to treatment protocols by staff to ensure uniformity of treatment practices). Four programs indicated they did employ some form of accountability measure. Unfortunately, it is unclear what methods are employed since the question did not ask for elaboration. Fraser South noted that the carepath attempts to serve this function and that chart audits of practice were conducted in the development of the carepath.

One program is known to have completed and disseminated a comprehensive program evaluation funded by the health authority (Fraser South). Another program has also presented extensive data analysis of its operations and outcomes (Victoria).

......... ......... .

24

Research

Two programs indicated they were actively engaged in research. Victoria noted involvement in three studies (medication, national outcomes, nutrition). It was unclear if any of these were specific to early psychosis. Fraser South indicated a number of studies. One, the Pathways to Care and Cognition study was specific to Fraser South clients. Other collaborative studies involving Fraser South clients included: Cognition, MRI and DNA study; CBT Group study, Education History study, Patient Perception of Functioning Scale Validation study; Valocyclovir trial study, Perception of Risk for Psychosis study, First Episode Psychosis and SocioEmotional Development in Young Adults with Psychosis study (Ph.D. dissertation). Several other smaller studies are also in progress.

Only three programs affirmed that they created and distributed

documents such as policy papers, advocacy manuscripts or research findings (Fraser South, Victoria, Queen Alexandra).

Priorities and Planning

Programs were asked to describe their future plans for service delivery, training, education and the largest obstacle they face. Several general themes emerged regarding service delivery improvements. Many programs saw continued development of clinical expertise as a priority even though the areas of training varied from CBT to group work to family therapy. Numerous respondents also mentioned better program evaluation and outcome assessment. Enhanced ability to provide appropriate housing and quality service to substance abusing clients were cited repeatedly. Some programs tempered their desire to do more public education with

the caveat that increased case finding should be accompanied by adequate clinical capacity to handle the increased numbers of referrals. Lack of integration was a noteworthy obstacle. Failures to have designated psychiatrist involvement and poor coordination across hospital and community care are two examples of inadequate integration. Other obstacles frequently mentioned included inadequate funding/resources or a lack of secure funding. Details for each program’s comments on priorities, plans and obstacles are contained in Appendix 3.

....... .. ...... ... .

25

Communities with Programs Compared to Communities without a Program

The presence of a program was used to divide communities into two groups that were then compared on quantitative variables from Part A of the survey.

Although the percentages of respondents who answered “Yes” favored programs, statistically significant differences were not found. In part, this was due to the low statistical power arising from the small sample sizes. The following variables showed no significant differences: the presence of a functioning early psychosis committee in the area (programs 82%, no program 70%), whether staff received copies of the Care Guide (programs 91%, no program 89%), whether outcomes were measured for each client (programs 64%, no program 38%), whether pathways into care are clear and easy to use (programs 73%, no program 50%), whether there is a single intake number for

referrers to call (programs 91%, no program 60%), average wait from assessment to start of treatment time within 72 hours (programs 44%, no program 22%), excellent or good rating of clinician skill level with early psychosis clients (programs 89%, no program 50%), and excellent or good rating of time allotted for early psychosis work (programs 56%, no program 14%, p=.12).

Those variables approaching significance included: whether continuity of care is problematic (programs 70%, no program 100%, p=.07), rating of physician expertise in handling early psychosis clients was borderline significant (excellent and good responses combined=programs 89%, no program 29%, p<.06), whether EPI was believed to have been helpful (programs 91%, no program 67%, p =.09) and respondents’ ratings of excellent or good regarding the accessibility of services (programs 80%, no program 33% p =.09).

The sole variable that favored non-program areas was the rapidity of face-to-face assessment within 72

hours after referral (programs 40%, no program 67%).

These results suggest that clients serviced by programs enjoy advantages in a number of domains thought to be indicators of best practices. Despite the fact that statistical significance was not achieved in the comparisons, the differing percentages favoring programs was noteworthy for variables relating to accessibility, physician expertise, and the benefit of the provincial EPI endeavor. The rating of clinician skill level would have reached significance if the respondent (Fraser South) who stated that skill levels vary had rated the overall skills of clinicians as “good”.

......... ......... .

26

27

T his survey intended to provide a cross sectional sampling of developments in early psychosis services across BC. It is not a definitive or exhaustive review. The overall sample

of 10 hospital units and 23 community-based services is sufficient to provide some insight into early intervention services and the challenges facing both rural and urban communities.

It appears that a quiet evolution has occurred over the past five years. Awareness of the role of early intervention in treating psychotic disorders has undoubtedly increased as every area of the province reported receiving information or benefiting from centrally based efforts beginning in 1999. Attendance at clinical training events was widespread. A loose patchwork of dedicated clinicians and administrators has grown as the value of early intervention takes hold in many communities. However, the lack of response from almost half of those surveyed is disappointing. Whether it suggests that early intervention does not occupy a high place on priority lists is a speculation that cannot be confidently answered. The survey and the authors’ personal contacts indicate that an enthusiasm among many has been generated for greater adoption of the principles and practices of early intervention. How this enthusiasm is translated into actual services appears to vary across the province. Certainly some programs must look with envy to a solitarily clinician or small group of clinicians who are implementing best practices while coping with few resources and numerous conflicting demands on their time.

The survey results suggest that community services have outpaced hospitals in attempting to incorporate more principles and practices advocated by the early intervention movement. About half of hospital respondents reported a lack of training for ER staff in early psychosis and limited improvement in handling these cases in recent years. Several hospitals’ responses were very encouraging. For example, Royal Jubilee not only reported affirmatively to every query regarding treatment protocols but they also indicated good transitional efforts from inpatient to community care. The Victoria program began as a hospital-based endeavor and the good community-inpatient interface may have resulted because of this origin. Most other services across the province appear to be essentially community based and often do not interact in a coordinated manner with inpatient services. This lack of integration is one peril of community-initiated programming. Further work to overcome the schism between hospitals and community care is imperative. Although about half of the hospitals reported advances as shown by the use of protocols and other indicators, some disconcerting results also arose. It appears that only UBC hospital is actively improving its capacity to assist early psychosis cases. Both Vancouver General and St. Paul’s Hospital lagged behind all other hospitals surveyed on the indicators used in the survey. Vancouver General appeared less familiar with early intervention principles and commented that they

......... ......... .

28

had difficulty distinguishing the needs of first episode cases from those on the ward with more chronic illnesses. It would come as no surprise if this finding were replicated in other hospitals with a larger sample. Almost half the hospitals reported that no early psychosis training had been given to ward staff. This is unfortunate since studies in Canada show that most first episode cases enter the mental health system via inpatient facilities (3) (4).

Turning to community services, the general survey found respondents generally gave good ratings for the training, knowledge, and skill levels of practitioners. However, the amount of time these clinicians are allotted to pursue early intervention work was less satisfactory. It must be noted that clinicians need to be given sufficient time to engage and treat clients or else the ability to even approximate best practices is severely compromised. The early intervention paradigm places great emphasis on intense psychosocial treatment that must be maintained for several years (5). Early intervention programs with aggressive case

finding strategies do reduce the duration of untreated psychosis (6). However, reduction of untreated psychosis alone is not sufficient to guarantee better outcomes (7) (8). Clinicians need training and the time to carry out intensive psychosocial interventions. Also, the majority of respondents noted that providing continuity of care was problematic. Some sites specifically indicated that dropouts were related to an inability of clinicians to provide the level of intensity required for early intervention work. Although there is no easy solution to the problem of limited time given sizable caseloads, one possibility involves rejecting the time-honored practice of hour-long sessions in favor of shorter meetings. Given that many of these persons have accompanying cognitive deficits such as difficulty sustaining attention and learning new material, it is clinically justified to see someone for a shorter period. This could also free up some time to engage in more assessment and outcome (i.e. measurement) activity.

Twelve respondents indicated the operation of an early psychosis

program. The composition, goals and breadth of these programs varied considerably. Most stated they provided basic services such as medication management, case management, education and psychosocial interventions such as stress management and supportive counselling. Even the most well developed programs reported or hinted at significant deficiencies that would preclude them from being considered “world class”. Many programs, especially those in rural areas and Vancouver, appeared to spend considerable effort on public education but were lagging in their capacity to deliver comprehensive interventions.

The case finding ability of programs might be estimated from epidemiological estimates of incidence of psychosis. The lack of clarity of the role C&Y played in some catchment areas makes it difficult to gauge how well programs are doing in managing to see most of the new cases that arise per year. However, it does appear that several programs may be seeing most new cases that arise in their catchment areas.

....... .. ...... ... . + discussions

29

The finding of a lack of significant correlation between population size and referral acceptance rates is not necessarily to be interpreted negatively. It may reflect increased sensitivity of gatekeepers and the public to the possibility of a potential psychotic process and the willingness to refer. Public education campaigns might be expected to produce such a pattern. Alternatively, referrals that are not accepted may result from other community agencies attempting to refer cases inappropriately in order to reduce caseloads. The issue of the mechanisms underlying referrals and acceptances must be answered by independent study specifically designed to answer such questions.

Population catchment area was completely unrelated to the number of standing cases in programs. The low standing caseloads relative to the yearly acceptance numbers suggest that clients are not being actively engaged in treatment by the program for a reasonable period. The standing ratios are of some concern for Fraser North, Vancouver, North Shore and Queen Alexandra programs. It is

unclear if this represents the intent of a given program (e.g. initiate pharmacotherapy and provide basic education) or a failure to be able to maintain treatment engagement. In either case, the result is a shortcoming, since intensive treatment should probably continue for at least one or two years.

All programs have to contend with shortages of time and resources. In some instances, the programs actually appear to be more like sub-programs operating within a larger service. This type of structure can dilute resources, lead to conflicting demands on clinical time, and limit program development. For example, the Hamber House Program is an innovative day treatment program for adolescents with psychiatric disabilities that prevent them from attending regular schools. The program did not affirm following a phase specific approach, is not intended to provide quick response to referrals, and does not accept clients with substance abuse or referrals from nonprofessional sources. It also tailors its case management type and group intervention content

according to the perceived needs of the clients and families. The work done at Hamber House appears to be consistent with a mandate to focus on clients with refractory illnesses. This helps explain why the program did not have statistics on the number of FE cases it was servicing. There is a great need for intensive day programming for those whose recovery from severe psychiatric disorder is prolonged and Hamber House is attempting to provide that service. However, it appears its criteria and approaches place it somewhat outside of this author’s concepts of what constitutes a specialized early intervention for psychosis program (i.e., one that emphases on reducing treatment delay, phase appropriate interventions, etc.).

The role of physicians in early intervention services is complex. It appears that, whereas some areas report significant involvement of psychiatrists, other services are operating with no formal affiliation with any psychiatrists. This situation was even true for some programs. It is unclear why there is a lack of

......... ......... .+ discussion

30

psychiatrist affiliation in some areas. For example, in Kelowna a single psychiatrist (plus one adult mental health clinician) attends to almost all adult clients, but the Child and Youth clinician has no specifically identified physician with whom she can work. Whether the obstacle is historical or structural (i.e. private practice model), psychiatrists need to become better integrated into a team approach if the best care possible is to be realized. The lower ratings for physician expertise by respondents for communities with no designated program are also a concern. The possible reasons behind this finding merit some thought. It is beyond the scope of the survey to comment on the physicians’ pharmacotherapy practices. Evidence from the Fraser South program evaluation suggests that atypical antipsychotic medications, one of the major advances in treating early psychosis, are prescribed to almost all first episode clients (9). There is little reason to suspect that this practice is not also being conducted throughout the province. This raises the possibility that other factors led to some of the ratings described

above. Although the reasons behind these ratings are difficult to ascertain, (e.g. lack of familiarity with psychiatrist practice, feedback from clients, disagreement with psychiatrist practice, etc.), the poor ratings suggest that a number of communities do not view psychiatrist practices favourably.

The one survey response that did directly address pharmacotherapy concerns the prescription of antipsychotics to clients who are suspected of being in a prodromal state. These clients appear to be at high risk for developing psychosis. The percentage of clients at risk prescribed antipsychotics is not known. This practice is highly controversial since a false positive identification places individuals at risk for stigma, anxiety, family discord, side effects and other negative repercussions. The most sophisticated identification systems in the world do not achieve conversion rates to psychosis of even 50% within a year (10). Therefore, even in the presence of strong clinical skills, it is highly unlikely that individuals in BC would achieve prediction

rates of close to 50%. Furthermore, despite individual claims of success using this approach, it would be impossible to ascertain whether the drug was responsible for the success or whether it was due to other interventions that occurred simultaneously (stress reduction, spontaneous remission of deterioration etc.). Research is underway that examines the viability of this practice (11). The author encourages those currently engaged in what is still a research practice to carefully inform clients and families of the risks and benefits of the practice, to thoroughly measure their results within a sound research methodology, and then to publish their results so that others can learn about the success or failure of the approach.

Psychiatrists are an extremely valuable professional group with excellent training, skills and influence. It is imperative that they become more integrated in partnerships with other caregivers. Closer ties with psychiatry will not only lead to more optimal care but would also greatly assist with program development.

....... .. ...... ... . + discussions

31

In locales where psychiatrists have provided strong participation or leadership, the advancements can be impressive. In British Columbia, there are a number of psychiatrists whose interest and commitment have been vital to the establishment of programs advocating for improved early intervention practices and facilitating research activity. Regions that do not have this level of support are strongly encouraged to find ways to bring more of these individuals into the early intervention movement.

Personnel issues may also underlie some of the results derived from the comparisons between programs that have some dedicated staff time versus those areas without programs. The analyses involving areas with early psychosis programs and communities without a designated program revealed that accessibility, clinical expertise, continuity of care and several other indicators of practice are considerably better where programs have been developed. Despite the drawbacks of many programs in the lack of depth and comprehensiveness of their services, their apparent

superiority argues for the continuing initiation and refinement of specially designated early psychosis programs in more communities. Finally, strong leadership is essential for the development and maintenance of programs. This leadership must occur both at the administrative level (i.e., ministerial, health authority) and at the program level (program directors, medical directors, etc.)

The early intervention approach to psychosis has helped combat the therapeutic pessimism associated with schizophrenia and other disorders. Clinicians across the province working with first episode patients within this model of care informally report seeing much better outcomes for their psychotic disorder cases than many had seen in their careers. The arguments that resources currently allocated to persons with chronic illness should not be shifted to early comprehensive services or that schizophrenia inevitably results in poor outcomes are flawed. The former argument neglects to recognize that the logic of “late intervention” is a recipe for allowing early psychosis clients to

develop into chronic clients. The latter argument is an artifact of the diagnostic, conceptual and social systems that focused on the poor outcome end of the whole spectrum of outcomes that do occur. Improved outcomes across the entire spectrum of clients who develop a psychotic disorder is the overarching goal of early psychosis services.

......... ......... .+ discussion

32

Limitations of the Survey

A number of shortcomings are apparent when a survey such as this is attempted. First, a less than comprehensive representation of available services resulted from the limited number of respondents. In particular, it is difficult to comment on how Child and Youth Mental Health Teams are providing services when they are not associated with an identified program. It is known that MCFD has embarked on a variety of laudable initiatives to increase early intervention services. Province-wide training of clinicians, reviews of best practices and strong central support from the management at MCFD are extremely valuable efforts that are largely untapped by this survey. Second, the quality of the information is dependent upon respondents’ available data. In some cases, approximations were used which could compromise the quality of the resulting analyses. Therefore, the numbers associated with a particular program may not be as exact as those provided by others thus rendering

comparisons across programs less reliable. This probably also reflects the data gathering capacity of some programs. Some programs have implemented extensive monitoring and measurement systems whereas others have very limited data systems. Third, the indicators used in the survey may not adequately capture many relevant domains of care. For example, medication type, dosing, use of restraint, length of stay, ward atmosphere and many other relevant indicators were not included. Finally, such a survey is partly obsolete by the time it is released. The author has tried to incorporate any new developments that were garnered from conversations with many clinicians across the province in the preceding months. However, this is bound to be incomplete with the result that certain programs, hospitals or generic community services will be inadequately represented.

The data generated by the surveys raises as many questions as it answers. Perhaps the largest question concerns how many best practices are being followed and

what effects on outcome are being generated by the interventions currently utilized. It is hoped this discussion will be recognized for its limitations and that the conjecture and speculation it contains act as a springboard for self- examination, more communication among those working in early intervention, and spirited debate about how services are developed, supported, executed and maintained.

....... .. ...... ... . ....... .. ...... ... .

“The data generated by the surveys raises as

many questions as it answers”

+ discussions

33

T he current state of early psychosis services in BC appears to vary widely across geographical areas and type of setting (hospital versus community). This is

not unexpected given the diversity of funding and managerial supports. The fine efforts made initially by the Ministry of Health and currently by the MCFD have been helped immensely by a number of the Health Authorities. Unfortunately, it appears that some health authorities retain a balkanized approach (that perhaps reflects the consolidation of the number of health regions several years ago). Unless a concerted effort is made across entire regions via directives by the highest levels of authority, a patchwork of services reflecting more local commitment might be expected to continue. This may be responsible for the significant variability in service development within a given region.

Although previous data is lacking, it appears that significant progress has been made in providing early psychosis services. A number of programs have been established and appear to be superior on many of the service indicators employed in the survey when compared to areas without programs. Several quite comprehensive programs currently exist in larger centers and excellent work appears to be occurring despite limited resources in some medium sized cities and rural areas. Throughout the province hard working, competent and enthusiastic personnel now exist who are striving to provide the best service possible according to the precepts of the early intervention movement. These clinicians and administrators desperately need support from higher levels of management to truly pursue optimal care, rather than to simply be handed the early psychosis portfolio without adequate training and the collegial organization needed for their work to be effective and comprehensive.

Conversely, several programs appear to be lacking many of the ingredients that could be argued are essential to the definition of a program. This very issue was raised at the recent International Early Psychosis Association Meeting. It is hoped that a communication from that body will be developed to further assist those planning and operating programs to achieve high standards. A related issue concerns the limited commitment to research and to the evaluation of practice at local levels. Levels of both outcome and process evaluation were disappointing, albeit with several notable exceptions. Several respondents noted they were leaving these types of activities to the larger programs such as Fraser South. Insufficient time and expertise represent the most likely reasons for these deficiencies. However, there may also be a belief that such activities are of limited relevance to a clinical practitioner. One hospital manager commented that the lack of a psychologist to assist with program development, evaluation methodology and statistical analysis was a significant roadblock, especially in an environment that merely pays lip service to the importance of service evaluation. The belief that such activity

......... ......... .

34

is largely irrelevant is far from true given the mounting pressure to justify the intense service provision demanded of many evidence-based practices including early psychosis intervention. Merely starting a service and expecting that best practices will be followed and will produce the intended results cannot be safely assumed. When a community faced with extreme limitations attempts to initiate a service, it may be better to do a limited number of interventions well than do a large number inadequately. The recently developed program in Kamloops appears to be concentrating first upon that which the clinicians are most competent to currently carry out (i.e., a focus on assertive case management, lifeskills training and recreation). They have currently restricted their entry criteria to maximize the potential effectiveness of their chosen interventions. This seems perfectly reasonable as a starting point. Additional services can come into play as competence and resources are developed.

The themes of under-resourcing, lack of integration across inpatient

and community services, lack of integration among medical and non-medical practitioners, and inconsistent support from management continue to hinder development. The standards indicating when an acceptable level of care has been achieved are themselves open to debate. If the standards of best care outlined in the CareGuide or other published guidelines (12) are the criteria, then BC, relative to other western countries, might receive a report card score of C+. However, if the standard is where the province stood 10 years ago, then the grade might be closer to A-. Many early psychosis clients have greatly benefited from the advancements to date and congratulations are due to those who have made those benefits occur.

It is a serious concern that clients and families across BC can find high-quality, intensive and continuing care available in some regions but not in others. The dissemination of guides to best practice does little to ensure that these practices are met. Combination strategies such

as small group debates on practice, reminder systems, quality assurance practices, and ongoing training and education are needed to help implementation. Although greatly needed, it is not enough to simply hire more staff. Rather, both medical and non-medical personnel must be aided to maintain fidelity to treatment protocols and demonstrate that their practices are producing the intended outcomes. These emphases will place early psychosis intervention at the forefront of evidence-based practice in medicine as a whole and mental health in particular. It is only through the combined will and integrity of the funding bodies, managers, and practitioners themselves that universal application of the early psychosis intervention model can be achieved in British Columbia.

....... .. ...... ... .

“When a community faced with extreme limitations attempts

to initiate a service, it may be better to do a limited number of

interventions well than do a large number

inadequately”c

35

Appendix 1 - Hospital Survey by Hospital

Appendix 2 – Hospital Survey by Hospital (continued)

Appendix 3 - Priorities, Plans and Obstacles of Programs

......... ......... .

a

36

37

AP

PE

ND

IX 1

- H

OS

PIT

AL

SU

RV

EY

BY

HO

SP

ITA

L

Trai

ning

in F

E

for s

taff

done

FE n

on-E

R

prot

ocol

s fo

r ph

ysic

ians

FE

prot

ocol

s fo

r non

M

Ds

Sta

ff tra

inin

g fo

r ER

sta

ff in

FE

Fam

ily

educ

atio

n pr

otoc

ols

used

Dis

tinct

D

isch

arge

pr

otoc

ols

Pos

t-hos

p re

ferr

al

targ

et fo

r FE

ca

ses

FE s

een

by c

omm

st

aff p

re

disc

harg

e

Daw

son

Cre

ekYe

sN

oN

oN

oN

oN

oYe

sN

o

Pea

ce A

rch

Yes

No

No

No

Yes

Yes

Yes

Yes

Por

t Alb

erni

No

No

Yes

Yes

Mis

sing

.Ye

sYe

sYe

s

Ric

hmon

d G

ener

alYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

s

Roy

al J

ubile

eYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

s

St-J

osep

h C

omo

No

No

Yes

No

Mis

sing

.N

oYe

sN

o

St-P

aul’s

Hos

pita

lN

oN

oN

oN

oN

oN

oN

oN

o

Sur

rey

Mem

oria

lYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

s

UB

C H

ospi

tal

Yes

Yes

Yes

No

Yes

Yes

No

No

Dun

can

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Vanc

ouve

r Gen

eral

No

No

No

No

No

No

No

No

FE =

Firs

t Epi

sode

.......

.. ......

... .

AP

PE

ND

IX 1

- H

OS

PIT

AL

SU

RV

EY

BY

HO

SP

ITA

L1

38

AP

PE

ND

IX 2 – H

OS

PITA

L SU

RV

EY B

Y HO

SP

ITAL (C

ON

TINU

ED

)

Do you keep

separate statsIf yes how

may

FE in past yrD

o you have num

bers of FE seen em

erg versus ward

Spec services for FE

Has EPI

helped youStaff got

CareG

uideA

re you improved

since EPI ended

Daw

son Creek

No

..

No

YesYes

No

Peace Arch

No

.N

oN

oYes

YesYes

Port Alberni

No

.Yes

No

YesN

oYes

Richm

ond Hosp

No

..

No

YesYes

Yes

Royal Jubilee

Yes84

YesYes

YesYes

Yes

St-Joes Com

oxN

o.

No

YesYes

YesN

o

St-Paul’s N

o.

.N

oYes

YesN

o

Surrey Mem

Yes9

No

YesYes

No

Yes

UB

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39

DUNCAN Plans and Priorities for Services: Expand day program and rehab capacity; refine assertive outreachTraining and Education: Increase skill in CBT

HAMBER HOUSE: Plans and Priorities for Services: Increase staff; increase outreach capacity and transitional follow-up; improve links with MH teams and better linkage to inpatient unitsObstacles: Not enough staff; inadequate coordination

FRASER NORTH Plans and Priorities for Services: Increase research and program evaluation capacity; enhance clinical training; develop alcohol and drug programming; develop mission statement and treatment protocols; cooperation with other EPI programs; Training and education: Ongoing community presentations plan quarterly clinical training sessions and annual clinical dayObstacles: Local managerial support, lack of acceptance by community physicians; lack of protection of clinicians’ case loads; missed cases

FRASER SOUTH Plans and Priorities for Services: Hire vocational therapist; modify services per recently completed program evaluation; develop carepath for inpatient streams and a community psychiatry carepath; establish residential facility; better day programming; improved multicultural outreach; annualized funding specifically for early psychosis ; better treatment for comorbidityTraining and education: Training for clinicians in family work and group therapy, survey clinicians to identify further needs, Obstacles: Lack of dedicated time for community clinicians for EP clients; lack of family work orientation of adult mental health clinicians; transportation problems due to large geographical area; consistent application of best practices across all sectors by both clinicians and psychiatrists

KAMLOOPS Plans and Priorities for Services: Transitional and subsidized housing; move to more acceptable location (outside of a MHC); restrict caseload to only early psychosis cases; begin establishing program evaluation and research capacity; Training and education: Desire more training in CBT and group facilitationObstacles: Lack of clarity regarding intake criteria – no current formal resource for at-risk clients

....... .. ...... ... .

APPENDIX 3 - PRIORITIES, PLANS AND OBSTACLES OF PROGRAMS3

40

KELOWNA Plans and Priorities for Services: Training and education: increase public awarenessObstacles: Lack of resources – increase case detection by public education will demand more staff

NORTH SHORE Plans and Priorities for Services: Start using outcome measures; develop group interventions especially OT; more staffTraining and education: School presentations; hospital ground rounds presentationsObstacles: No designated psychiatrist; more funding for staff

TERRACE Plans and Priorities for Services: Expand group topics to include assertiveness and relaxation trainingTraining and education: Increased public educationObstacles: Lack of time given high caseload – need managerial support

VANCOUVER Plans and Priorities for Services: Increase assessment and treatment capacity; start group for clients and families; connecting with clients when still in hospital; cooperate with other EPI programsTraining and education: New public awareness campaignObstacles: Lack of funding; fractionation of diverse services working in the area demands greater alliance building

VERNON Plans and Priorities for Services: Increase public education componentTraining and education: More public educationObstacles: Funding inadequate; inadequate time

VICTORIA Plans and Priorities for Services: Planning for concurrent disorders; better interface between inpatient and community services; neurocognitive assessment capacity; improve rehabilitation programming for youth; more case managersTraining and Education:Obstacles: Lack of funding

QUEEN ALEXANDRA

Plans and Priorities for Services: Provide tertiary service for the age group served to all of Vancouver IslandTraining and educationObstacles: Transitional procedures from C&Y to Adult

41

1. Ehmann TS, Hanson L, editors. “Early Psychosis: A Care Guide”. Vancouver: University of British Columbia; 2002.

2. Ministry of Children and Family Development. Child and Youth Mental Health Plan for British Columbia. Victoria: Government of British Columbia; 2003.

3. Addington J, Van Mastrigt S, Hutchinson J, Addington D. Pathways to care: help seeking behaviour in first episode psychosis. Acta Psychiatr Scand 2002;106(5):358-64.

4. Norman RM, Malla AK, Verdi MB, Hassall LD, Fazekas C. “Understanding delay in treatment for first-episode psychosis”. Psychol Med 2004;34(2):255-66.

5. Linszen D, Lenior M, De Haan L, Dingemans P, Gersons B. “Early intervention, untreated psychosis and the course of early schizophrenia”. Br J Psychiatry Suppl 1998;172(33):84-9.

6. Malla A, Norman R, McLean T, Scholten D, Townsend L. ”A Canadian programme for early intervention in non-affective psychotic disorders.” Aust N Z J Psychiatry 2003;37(4):407-13.

7. de Haan L, Linszen DH, Lenior ME, de Win ED, Gorsira R. “Duration of untreated psychosis and outcome of schizophrenia: delay in intensive psychosocial treatment versus delay in treatment with antipsychotic medication”. Schizophr Bull 2003;29(2):341-8.

8. Malla AM, Norman RM. “Treating psychosis: is there more to early intervention than intervening early?” Can J Psychiatry 2001;46(7):645-8.

9. Tee K, Ehmann T, Hanson L. “Evaluation of the Fraser South Early Psychosis Intervention (EPI) Program”. White Rock: Fraser Health Authority; 2004.

10. Yung AR, Phillips LJ, Yuen HP, Francey SM, McFarlane CA, Hallgren M, et al. “Psychosis prediction: 12-month follow up of a high-risk (“prodromal”) group”. Schizophr Res 2003;60(1):21-32.

11. McGorry PD, Yung AR, Phillips LJ, Yuen HP, Francey S, Cosgrave EM, et al. “Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms”. Arch Gen Psychiatry 2002;59(10):921-8.

12. “Australian clinical guidelines for early psychosis”. Melbourne: National early psychosis project, University of Melbourne; 1998.

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42

1HOSPITAL SERVICES SURVEY

1 Do you keep separate statistics for First Episode/Early Psychosis cases? YES NO

2 If yes, how many First Episode cases were treated in the past year?

3 Also, do you know the breakdown between those admitted to ward versus seen-only in the Emergency Department? YES NO

4 Do psychiatric ward staff receive special training in First Episode/Early Psychosis? YES NO

5 Are there specific protocols non-ER (i.e. psychiatric ward) physicians follow for handling these cases? YES NO

6 Are there specific protocols non-physicians (psychiatric ward) follow for handling these cases? YES NO

7 Are there any specialized services for first episode cases such as assessments or groups? YES NO

7a. If yes, describe or attach those protocols

7b. Are there family education/support protocols? YES NO

8 Do you have distinct discharge protocols for these cases? YES NO

9 Is there an identified community-based service that you refer patients to for post hospital care? YES NO

10 Is it policy for FE cases to be seen by community staff prior to discharge? YES NO

11 Are Emergency Department staff trained specifically regarding First Episode cases? YES NO

12 What are the biggest advances in your handling of these cases over the past year?

......... ......... .

HOSPITAL SERVICES SURVEY

Tom Ehmann, PhD. – Provincial Early Psychosis Liaison A Partnership with the BC Schizophrenia Society

2 HOSPITAL SERVICES SURVEY

13 What are your biggest obstacles in handling these cases?

14 What are the highest priorities needed to make your service more effective in handling these cases?

15 Do you believe the BC EPI (1999-2001) had any positive effect on your handling of FEP cases? YES NO

16 Have clinical staff received copies of the 2002 EPI-produced document “Early Psychosis: A Care Guide”? (This does not refer to the 20 page executive summary) YES NO

17 Has your ability to effectively treat EP patients improved since the BC EPI ended in Mid-2001? YES NO

Additional comments:

1OUTPATIENT SERVICES SURVEY

1 What is the name of the catchment area? YES NO

2 Do you service Adult, Child/Youth or both populations? (choose one) Adult Child & Youth Both

3 Population of your catchment area (i.e. of target population)

4 Is there a functioning early psychosis (EP) planning committee? YES NO

5 If you answered Yes on Q. 4, who comprises this committee? (i.e. job designations, government or non-government affiliation).

5a. How often does this committee meet?

6 Are there services specifically designated as “Early Psychosis” or “First Episode”? YES NO

Survey Instructions:

This survey consists of two parts: Part A – is for all community-type services, while Part B – is a more detailed questionnaire to be completed by those who have a more formal Early Psychosis Program. Such programs exist in Victoria, Central Island, Vancouver, Fraser, Okanagan (and there may be others). Most people will only need to complete Part A. However, please check out Part B and fill it in if you find it useful to describe your services.

Part A:

......... ......... .

OUTPATIENT SERVICES SURVEYFOR ALL COMMUNITIES GOVERNMENT/HEALTH AUTHORITY RESPONDERS

Tom Ehmann, PhD. – Provincial Early Psychosis Liaison A Partnership with the BC Schizophrenia Society

2 OUTPATIENT SERVICES SURVEY

6a. If yes, how does your service define “early psychosis”? (choose one) First Episode – any duration of treatment Any episode but within the first 5 years since first treatment Other (please define) ______________________________________

6b. If yes, what types of services are offered? (Please check all that apply) medication management case management groups education to patients education to families training other therapies other (please specify) _________________________________

6c. Any other comments on services offered?

7 Are there staff designated as having specialized competence and who handle most of these cases? YES NO

8 Are EP clients simply seen as part of larger routine services? YES NO

9 What is the number of First Episode/Early Psychosis clients seen as outpatients in your area by these staff?

10 Do you believe the BC EPI (1999-2001) positively influenced your handling of FEP cases? YES NO

11 If yes, in what way did it influence your services & delivery?

12 Have clinical staff received copies of the 2002 EPI – produced document “Early Psychosis: A Care Guide” (not just the 20 page executive summary)? YES NO

13 Have there been training events on early psychosis for clinicians in the past year? YES NO

13a. If yes, how often were events held?

3OUTPATIENT SERVICES SURVEY

13b. If yes, about how many people attended these events and who were the audiences (i.e. Physicians, Mental Health Clinicians)

14 Are public education activities on early psychosis ongoing? YES NO

14a. If yes, how often were events held?

14b. If yes, approximately how many people attended these events and who was the audience (i.e. youth, gatekeepers)?

15 Do you measure outcomes for each patient? YES NO

15a. If yes, what are the main outcome measures used?

16 What do you think are the greatest needs to further EP work in your area?

17 What are your greatest advances so far?

4 OUTPATIENT SERVICES SURVEY

18 What are the biggest obstacles?

19 What assistance do you need the most?

20 Are Referral Pathways clear and easy for clients/families to use? YES NO

21 Is there a single number to call for all possible clients (i.e. central intake)? YES NO

22 What is your rating of how accessible services are for FEP clients (exclude hospital entry)?

Excellent (e.g. easy to find-single point of entry, self-referrals accepted) Good (between excellent and moderate) Moderate (several different entry points – restrictive referral criteria) Fair (between moderate and poor) Poor (multiple numbers to entry, confusing to find services, very restrictive entry criteria)

23 What is your rating of how rapid the response of community care is (i.e. how quickly the person is assessed in person as an outpatient)?

Face to face assessment for almost all clients within 24 hours Almost all clients assessed within 72 hours Almost all clients assessed within one week Almost all clients assessed within two weeks Greater than two week wait for most clients

24 What is the typical waiting period between assessment and the start of treatment? Face to face treatment within 24 hours for almost all clients Almost all clients seen within 72 hours Almost all clients seen within one week Almost all clients seen within two weeks Greater than two week wait for most clients

5OUTPATIENT SERVICES SURVEY

25 What is your rating of the knowledge/skill level of clinicians working with FEP clients?

Excellent Good Moderate Fair Poor

26 What is your rating of the knowledge/skill level of most of the physicians prescribing medications to EP clients?

Excellent Good Moderate Fair Poor

27 What is your rating of the time allotted for those working with FEP clients to follow best practices?

Excellent (e.g. lowered case loads for those with first episode cases) Good (between excellent and moderate) Moderate (efforts made to allow increased clinician contact time) Fair (between moderate and poor) Poor (no formal recognition of need for greater contact with clients and families)

28 Is ensuring continuity of care a problem? YES NO

29 If yes, what do you think are the major contributors? Client improves and no longer desires service Client drops out for other reasons Staff cannot provide sufficient intensity of contact to properly engage client Frequent staff changes or transfers of clients to other services Other (describe) _____________________________________________

Other additional comments (this is the last question for those without formal programs)

6 OUTPATIENT SERVICES SURVEY

Do you operate an Early Psychosis program? YES NO

If yes, please describe the service by responding to the following:

1 Start date:

2 Referral sources:

3 Criteria for admission to program...

3a. Age range served:

3b. Maximum length of treated psychosis allowed (i.e. first episode or first few years):

3c. Co-morbid conditions (e.g. substance abuse) allowed? YES NO

3d. Do you admit non-affective psychoses? YES NO

3e. Other admission/exclusion criteria:

4 Catchment area name:

5 Catchment area population:

6 Staffing type and amount (professions and FTE allotments):

Part B:

7OUTPATIENT SERVICES SURVEY

7 Funding structure:

8 Is there an outreach component for assessment? YES NO

8a. Is there an outreach component for treatment? YES NO

9 If you are a community program, are inpatient activities clearly integrated (i.e. shared treatment/assessment protocols, etc. – contact with community staff prior to discharge, etc.?) YES NO

10 Length of time EP client is seen before transfer to regular care:

Program components11 11a Medication management YES NO

11b Education to clients and families) YES NO

11c Are groups offered? YES NO

11ci If yes, what topics? Education Stress Mgt Other (describe) ____________________

11d. Other comments on groups:

12 Social interventions individually given--- (stress management, problem solving, symptom management, etc:) YES NO

13 Cognitive therapy for psychosis: YES NO

14 Specialized assessments (e.g. psychology, vocational services) YES NO

15 Does the program explicitly follow a phase specific approach? YES NO

16 Are there written protocols for interventions? YES NO

8 OUTPATIENT SERVICES SURVEY

17 Type of case management provided (e.g. direct delivery versus brokerage, frequency of contact)

Brokerage Direct service Assertive outreach Other

18 Number of clients referred to program in past year:

19 Number of clients accepted into program in past year:

20 Number of clients currently on caseload (i.e. standing cases):

21 Please specify additional program elements (e.g. housing, work programs, case finding strategy, special programming):

22 Criteria for discharge from program:

23 How are dual diagnosis patients handled (especially those with substance abuse)?

Referred to A&D programs Integrated treatment provided by program Other

24 How do you handle the transition of clients from C&Y to Adult Services?

25 Are At-Risk (possible prodromal) clients accepted into program? YES NO

25a If so, is treatment provided by the service? YES NO

25b Are any At-Risk clients prescribed antipsychotic medication? YES NO

26 Public education approach and recent activities (describe)

27 Number of clinical training events in past year specific to Early Psychosis:

27a. Other training comments

28 Research activity- please describe –

9OUTPATIENT SERVICES SURVEY

Program evaluation29 29a. Do you use client satisfaction surveys? YES NO

29b. Are outcomes measured for every client? YES NO

29c. Are there measures of program accountability (i.e. measures of adherence to protocols by staff to ensure uniformity of treatment practices)? YES NO

29d. Other outcomes measured (economic utilization data etc) YES NO

30 Creation and distribution of documents such as policy papers, research, advocacy YES NO

31 Is there a written Mission Statement or program description (please attach)? YES NO

32 Please describe future planning for services:

33 Describe future planning for training and education:

34 Describe obstacles to providing services:

35 Describe priorities for further service development:

36 Other activities and comments

37 Please attach any documents (descriptions, protocols etc) you think would help us describe your work to others

British Columbia Schizophrenia Society201 - 6011 Westminster Highway

Richmond, BC V7C 4V4Tel: 604.270.7841 Fax: 604.270.9861

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Website: www.bcss.orgBN: 11880 1141 RR 0001