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www.england.nhs.uk
• Stephen McGowan, EIP Clinical Lead for Y&H CN and NHSE (North)
• Dr Steve Wright, Consultant Psychiatrist, TEWV (Co-Chair)
• Rebecca Campbell, Quality Improvement Manager and Sarah Boul, Quality Improvement Lead
• Rebecca.campbell6@nhs.net and sarah.boul@nhs.net
• Twitter: @YHSCN_MHDN #yhmentalhealth
• July 2016
Yorkshire and the Humber
Mental Health Network
Early Intervention in Psychosis Network
7th July 2016
www.england.nhs.uk
Yorkshire and the Humber
Early Intervention in Psychosis Network
Welcome!
Introductions
Aims, Objectives and Terms of Reference
Steve Wright, Consultant Psychiatrist, Tees Esk Wear Valleys NHS Trust
www.england.nhs.uk
@YHSCN_MHDN
#yhmentalhealth
Housekeeping:
www.england.nhs.uk
Scope
• The key focus of this group will be the implementation of the new mental health access and waiting time standards, and the NICE Guidelines.
• The group will also act as a community of interest in the issue of Early Intervention in Psychosis and related mental disorders that affect young people and their families.
Aims, Objectives & Terms of Reference (1)
Aim - 1 • In line with IRIS, the Network will influence service
developments that improve the lives of people affected by psychosis and their families by embracing the aims and principles of the Early Psychosis Declaration:
• Improve access, engagement and treatment of young people with emerging psychosis
• Recognise the importance of recovery and ordinary lives for those with early psychosis
• Support families and close friends who are dealing with the impact of early psychosis in a person they care about
• Raise community awareness about the importance of early intervention for psychosis
• Help practitioners from community and specialist mental health services deal more effectively with early psychosis
Aims, Objectives & Terms of Reference (2)
Aim - 2 • Ensure delivery of the regional EIP preparedness programme:
• Raising awareness of the requirements of the new standard
• Bringing together local experts and establishing quality improvement networks, ensuring effective linkage with strategic clinical networks
• Understanding levels of demand in constituent CCGs and any inequities in access relative to the levels and patterns of psychosis incidence in the population
• Understanding baseline performance and act on the gap analysis
• Optimising referral to treatment pathways, engaging all of the likely referral sources
• Preparing for the new data collection requirements and providing training for EIP service and information leads
• Supporting local workforce development programmes
Aims, Objectives & Terms of Reference (3)
Aim - 3 • In addition the Network will support the following:
• Information exchange
• Networking
• Sharing good practice
• Sharing resources e.g. job descriptions, operational policies etc.
• Identifying common problems and seeking solutions
• Areas with strengths and/or expertise will offer support to areas with developmental needs.
• Education
• Dissemination of information and communication from the National Team
Aims, Objectives & Terms of Reference (4)
Role • Unite individuals and partners across Yorkshire and the
Humber in a common purpose.
• Promote common understanding, joint working and
prevent duplication.
• Work collaboratively to build capacity and capability for
quality improvement in services.
Aims, Objectives & Terms of Reference (5)
Sign off? • Any comments or suggestions prior to sign-off.
• Review in 6 months
Aims, Objectives & Terms of Reference (6)
Overview:
• Purpose is to provide a mechanism for agreeing EIP priorities for the region
• In addition to oversee the Y&H EIP Network.
• Membership representative both of the geography of region and also of the key roles in EIP, including service
user and carers.
Comments & Feedback from the first meeting
Y&H EIP Steering Group
www.england.nhs.uk
Yorkshire and the Humber
Early Intervention in Psychosis Network
National and Regional Update
Moggie McGowan, EIP Clinical Lead (Yorkshire & The Humber),
NHS England North
www.england.nhs.uk
Yorkshire and the Humber
Early Intervention in Psychosis Network
EIP Audit – Self Assessment Tool
https://www.snapsurveys.com/wh/s.asp?k=146616273215
A DISCOURSE ON
THE
PSYCHOPHARMACOLOGY OF
FIRST EPISODE PSYCHOSIS
And an Historically Inaccurate and Whiggish Illustration of the Quandaries of
Diagnosis as pertaining to Modern Psychiatric Practice, leaning on the work of Messrs
Curtis and Elton
Presented By Dr Iain Macmillan
Consultant Psychiatrist EIP, Gateshead, NTW NHS Trust
Honorary Clinical Senior Lecturer, Newcastle University
And Regional EI Clinical Lead for Psychiatry, NHS England, North
EDMUND – ANNO 1590
HAS BEEN UNWELL
Generalised malaise
Symptoms -
• Cough at night disrupting sleep
• Pain in chest causing anguish
• Swelling of the ankles – unsightly and
uncomfortable
Seeking help
DOCTOR 1
Heart ache disorder
(melancholia) is the
problem! Imbalance of
the humours, excess
black bile!
PX EXTRACT OF WILLOW
BARK
DOCTOR 2
Nocturnal cough
disorder is the prime
problem, - Imbalance of
the humours -excess
phlegm.
PX DRAUGHT OF OPIUM
DOCTOR 3
The previous Doctors are fools
and quacks, the primary problem
is swollen ankle disorder - caused
by a humoural imbalance –
sanguinity (excess blood ).
PX LEECHES
Doctor: You know the leech comes
to us on the highest authority?
Edmund: Yes. I know that. Dr
Hoffmann of Stuttgart, isn't it?
Doctor: That's right, the great
Hoffmann.
Edmund: Owner of the largest
leech farm in Europe….
EVIDENCE –BASED LEECH THERAPY
DIFFERING OPINIONS
Different focus on presenting symptoms
Different explanations of aetiology
Different treatments offered
All to some extent effective
WILLIAM HARVEY –
PARADIGM SHIFT
DE MOTU CORDIS, 1628
Essentially descriptive: constructed in the age of steam
Observations of people with severe, established illnesses
Syndromes (poorly validated) equated with Diseases
Very few categories meet validity standards
Aetiological assumptions underpin diagnoses
OPCRIT rescued Psychiatry to some extent
Reliability OK in research settings, poor in clinical ones
Poor utility of diagnoses for treatment selection, research
AND T HE POINT OF T HIS TALE –
PSYCHIAT R IC DIAGNOSE S….
Back to the 21st Century….
Paradigm shift in progress?
Where am I now?
Contribution of psychiatric disorders to occupation of NHS beds: analysis of Hospital Episode Statistics.
Parvathy Pillay, Joanna Moncrieff DOI: 10.1192/pb.bp.109.028399 Published 31 January 2011
Bed Days – NHS resources – “current practice” doesn’t seem to be
working terribly well….
Pathophysiology
The black box of pathophysiology
Genetics
Stress
Syndromes Aetiology Mechanisms
Depression
Anxiety
Drug abuse
Childhood
adversity Psychosis
Environment
• Dopa/mine – implicated
Opening the black box of pathophysiology -
Howes et al Arch Gen Psychiatry. 2009;66(1):13-20
Bloomfield et al. AJP in Advance (doi: 10.1176/appi.ajp.2015.14101358)
Opening the black box of pathophysiology –
neuroinflammatory processes?
Opening the black box of pathophysiology -
Opening the black box of pathophysiology -
Autoimmune encephalitis
• Anti-VGKC complex(2005, 2010)
• LGI1
• CASPR2
• Anti-NMDA receptor (2007)
• Anti AMPA receptor
• GABA-B receptor
• Anti GAD
• Gly-R
• Thyroid peroxidase TPO (Hashimoto’s)
Opening the black box of pathophysiology
Maybe not just dopamine -
Effects of antipsychotics on inflammatory markers in schizophrenia:
CATIE study
C-reactive protein (CRP) changes:
olanzapine vs perphenazine (p<0.001)
and olanzapine vs ziprasidone (p=0.003) Meyer et al 2009
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
CRP
change
(mg/L)
0 3 6 12 18
Visit (month)
Olanzapine
Perphenazine
Risperidone
Ziprasidone
Quetiapine
Diagnoses
Where are we now? From the chair of the DSM IV
group?
“we are at the epicycle stage of psychiatry
where astronomy was before Copernicus
and biology before Darwin. Our inelegant
and complex current descriptive system will
undoubtedly be replaced by…simpler, more
elegant models.”
Frances AJ, Egger HL: Whither psychiatric diagnosis. Aust N Z J Psychiatry 1999; 33:161–165
DSM III-R Diagnoses in FEP cohort
Macmillan et al, Early Intervention in Psychiatry 2007
Pluripotential Early Stages with Growing
Syndrome Clarity?
psychosis
mania depression
psychosis
depression mania
Psychosis
depression mania
Stage 1a Stage 2+ Stage 1b
schizophrenia
Neurodevelopmental-staging model of psychosis
(T.R. Insel, Nature 2010; 468;187-193)
Stage
Definition
Interventions
0
Increased risk of psychosis or mood disorder (eg family history, abuse, substance use) No specific symptoms currently
Mental Health Literacy Self-Help
1a
Mild or non-specific symptoms of psychosis or mood disorder
Mental Health Literacy Family Psychoeducation Substance abuse, CBT
1b
Prodromal features: Ultra High Risk
1a plus Therapy for episode: ? phase specific or MS
2
First Episode Threshold psychosis or mood Disorder
1b & case management, vocational rehabilitation
3a
Recurrence of sub-threshold psychosis or mood symptoms
2 & emphasis on maintenance meds and psychosocial strategies
3b
First threshold relapse
2a & relapse prevention strategies
3c
Multiple relapses
3b & Combination/ mood stabilisers
4
Persistent unremitting illness
3c & clozapine and other tertiary therapies.
A staging model
McGorry ANZ JP 2006; Berk et al. Bipolar Disord 2007; Berk et al. J Affective Disord 2007
Known biomarkers by clinical stage
Stage
Structural MRI
•Hippocampus
•Frontal cortex
•Lateral ventricles
•Right superior temporal lobe
•Corpus callosum
•Amygdala
Neurocognition
•Intellectual impairment
•Executive function
•Verbal memory
•Working memory
•Sustained attention
•Response inhibition
•Symbol coding
Electrophysiology
•Impaired P50
•Deficits in P300
•Reduced mismatch
negativity
•Abnormalities in resting
state EEG spectra
Neuroimmunology
•Increased proinflammatory
cytokines (eg IL6, IL1, TNFa)
•Increased antiinflammatory
cytokines (eg IL10)
Oxidative stress
•Dysregulation of
antioxidant enzyme
activity
•Increased lipid
peroxidation
•Mitochondrial
dysfunction
HPA axis dysregulation
•Cortisol secretion
•Glucocorticoid receptor
activity
•Mineralocorticoid receptor
activity
•Pituitary volume
Sz BD MD Sz BD MD Sz BD MD Sz BD MD Sz BD M
D Sz BD MD
0 IQ?
CI? ?
MMN
?
1a IQ
CI? ? MMN ?
C
GR
1b FC
STL ? ?
IQ
CI IQ?
P50
P300
MMN
EEG
? ? ? ? ? ? ? ? C
? ?
C
GR
2
HV
FC
LV
STL
CC
? A? IQ
CI
IQ
CI CI?
P50
P300
MMN
EEG
P50
P300 ?
pro
anti
pro
anti pro
C
GR
PV
PV
C
PV
GR
MR
3
HV
FC
LV
CC
LV
HV
A?
STL
IQ
C
IQ
CI CI?
P50
P300
MMN
EEG
P50
P300 ? pro pro pro
C
GR
PV
PV
C
PV
GR
MR
4
HV
FC
LV
CC
LV
HV
A?
STL
IQ
CI
IQ
CI CI?
P50
P300
MMN
EEG
P50
P300 ? pro pro pro
C
GR
PV
PV
C
PV
GR
MR
Treatments
Stage 1b - ARMS
Antipsychotic medication
Medication requires expert and careful
consideration as these typically young
people, previously treatment naive, may
be embarking on treatments which for
some may be necessary for several
years.
Stage 2 – FEP
Antipsychotic medication
Most current antipsychotics show similar
efficacy against positive symptoms in
FEP. Thus choice of drug should be
based on tolerability and side effects
experienced, and the individual’s ability
to manage these whilst maintaining
therapeutic benefit.
(Leucht et al 2009)
Stage 2 – FEP Antipsychotic medication
Leucht et al, Lancet 2013
Lieberman et al 2003
Medications – more useful when taken….
Leucht et al, Lancet 2013
Antipsychotic medication – low dose
Dose recommendations of atypical antipsychotics in first-
episode non-affective psychosis – start low go slow!
Atypical Antipsychotic
Starting Dose
Initial Target Dose (to reach after 7 days, maintain for 3 weeks)
Full (max) target dose (increase slowly over 4 weeks, total trial 8 weeks) Amisulpiride
50-100 mg daily
300 mg daily
800 mg daily
Aripiprazole (1st line?)
10 mg daily
15-20 mg daily
30 mg daily
Clozapine (not 1st or 2nd line)
25 mg test dose
100-150 mg daily
200-300 mg daily
Olanzapine
2.5-5 mg daily
10 mg daily
20 mg daily (not recommended due to excess metabolic burden)
Quetiapine (?advantage in affective)
25 mg test dose
150 -400 mg daily
750 mg daily
Risperidone (1st line?)
0.5-1 mg daily
2mg daily
4 mg daily
(Adapted from Lambert et al, Pharmacotherapy of first-episode psychosis,2003)
Dose Equivalents
Leucht et al, Schizophrenia Bulletin Advance Access Feb 2014
“An adequate trial….”
Antipsychotic medication
This should be provided in conjunction
with a psychosocial and vocational
programme including physical, family
interventions and CBT-p, delivered by a
coherent specialist EIP service.
Antipsychotics – concerns arise
FGA vs SGA?
Some people may choose to avoid
medication and should not be made to
feel they are not cooperating. Indeed
although difficult to predict who,
evidence shows that some can do well
without medication. Offer CBT, Family
Therapy, CBT-informed case
management.
Antipsychotic medication
Stage 4 - Antipsychotic medication
Following careful review, consideration
should be given to the early use of
clozapine in people whose symptoms do
not respond to an adequate trial of two
different antipsychotic agents.
Antipsychotic medication – discontinuation?
Wunderinck et al JAMA Psychiatry. doi:10.1001/jamapsychiatry.2013.19Published online July 3, 2013.
Antipsychotic medication in FEP – stages 2-3-4
1. Involve service users in treatment choices
2. Young, neuroplastic brains – be gentle!
3. Actively manage metabolic risk from the outset
4. Start low, go slow
5. Be sensitive to side effects
6. Don’t persist with ineffective treatments, but
give adequate trial at a decent (not high) dose
7. No clear guide as to 1st and 2nd choice,
?SGA>FGA, Risperidone/Aripiprazole?
8. Discontinuation possible once stably recovered
– gradual with clear plan to manage relapse
9. 3rd choice Clozapine
Thanks for listening!
• Any questions?
Thanks to Pat McGorry and Michael Berk for some of the slides.
Edmund’s case developed from conversations with Michael Berk and Assen Jablensky.
Thanks to Messrs Curtis and Elton.
Post Graduate Diploma in CBT
(Secondary Care)
Kerry Smith 2015
Context:
• Professional training
• Funding from LETB to support local service development imperatives
• Training for the Diploma and Certificate is at level 7
• (Level 6 modules were offered as CPD elements to support staff not ready to progress at academic level 7 or as a precursor)
Knowledge and Skills Specific to Secondary Care:
• CBT competencies – Common anxiety disorders / mild to moderate depression (primary care)
• CBT competencies- Serious mental Illness (secondary care )
• Supervision competencies
Training Pathways
PG Diploma: • 4 taught modules and 2 supervised practice modules i)Basic theories and skills, ii)Common disorders in SMI iii)Psychosis and Bipolar, iv)PD and complex presentations
PG Certificate (theory): • 3 taught modules ( one of these for SMI competencies) PG Certificate with Clinical Practice (“Top-up”) • 1 taught module (Psychosis and Bipolar Disorder) • 2 supervised practice modules (Psychosis clients)
Trainees
• PG Dip: Current cohort: 23 (20)
• PG Dip: Cohort 2017: 23 offers
• Top- up : 4 (and counting)
Geography Served (in order of numbers)
• Humber • Leeds • Navigo • Bradford • Castleford • Dewsbury • Barnsley • Scarborough • Lincoln • Other ( non NHS)
Service context
• Increasing Access to Psychological Therapies (IAPT):
• primary care
• Children and young people
• Serious mental illness (SMI)
• EIP access standards
• NICE
Roth & Pilling competency framework
• Generic therapeutic competences – E.g., client engagement, dealing with emotional content
• Basic CBT competences – E.g., Structure, basic principles of cognitive psych and
behaviourism
• Specific behavioural and cognitive therapy – E.g., exposure, guided discovery, formulations
• Problem specific competences – ‘Models’ of disorders such as PTSD, OCD etc.
• Metacompetences – E.g., clinical judgement, choosing appropriate treatment
interventions
http://www.ucl.ac.uk/clinical-psychology/CORE/CBT_Competences/CBT_Competences_Map.pdf
Problem specific competences
• http://www.ucl.ac.uk/clinical-psychology/CORE/CBT_Competences/Problem_Specific_Competences/Problem_Specific_Competences.pdf
Who comes on our training course?
Core Professional Groups:
• Nursing
• Social work
• Clinical Psychology
• Counselling Psychology
• Occupational Therapy
• Psychiatry
Applicants via a Knowledge Skills and Attitudes ( KSA)Route
• Applicants who can demonstrate knowledge skills and attitudes equivalent of a core professional training.
• Need to submit a KSA portfolio at interview. Can be completed during the course. But initial draft must indicate near readiness at interview
• General nurses, PWPs, Psychology Assistants, Care coordinators
Selection
Application form:
• Needs to show service support and permissions for training are in place
Interview:
• Role play
• Reflection
• Questions
Teaching methods
• Teaching and guided reading: theory and practice
• Acting on knowledge in practice exercises in skills sessions, self therapy and clinical practice.
• Applying knowledge to new areas of CBT theory through academic writing: essays and exams.
• Reflecting on experiences by observation in workshops, by recording own practice and using rating scales to structure this thinking, by using supervision.
Trainee feedback:
• Course is demanding
• Value high content of skills based teaching and chance to observe practice
• (Always want more of this)
• The chance to focus on complex cases and comorbidity is good preparation for work in any service
Predictors of successful training
• Jolley, S., Onwumere, J.,Kuipers, E., Craig, T., Moriaty, A. and Garety, P. (2014)
• Increasing access to Psychological therapies for people with psychosis: Predictors of successful training.
• https://www.researchgate.net/journal/1873-622X_Behaviour_Research_and_Therapy
Successful training:
• Previous work as a CBT therapist
• Current role as therapist
• Previous academic study at masters level
Delivery after training:
• Found many trained stopped delivering therapy because of difficulties with workload and care- co duties
• Delivery is enhanced when therapists are employed in dedicated posts
How services can support training
• Management support in preparation for training • Supervisor identified early on (BABCP Accredited) • Supervisor facilitated to attend course supervisor events • Adequate recording facilities made available early on • Access to appropriate clients facilitated • Support given for seeing training cases for adequate numbers of sessions • Support to attend all teaching sessions • Support for study time if required • Avoid dual roles for training cases where possible: care co-ordinator and
therapist • Where service pressures prevent some of the practical measures above an
emotionally supportive environment can still help trainees to cope- trainees don’t expect unrealistic adjustments but need to know that mangers understand the extra challenges training involves
How services can support implementation of therapy post
training • Ensure that post training job roles allow dedicated time
for CBT practice and supervision
• Encourage CBT related CPD and consolidation
• Incorporate accreditation as a goal of staff appraisal
• Encourage investment in completing and consolidating training rather than taking up multiple training opportunities without completion.
• Nurture successful trainees as assets that can benefit colleagues through supervision and support and training
How we can support, post training?
• Supervisor workshops
• Masterclasses
• Support for accreditation
• Involvement in the training community
www.england.nhs.uk
Yorkshire and the Humber
Early Intervention in Psychosis Network
Time for a break?
1. Medication & Treatment
2. Role of the Care Coordinator
3. Developing the therapy workforce
4. Service Development & Challenges
• Key Priorities and Actions for Meeting the Standards
• Key Priorities and Actions for Overall Quality
Improvement
PLEASE NOTE KEY POINTS ON FLIPCHART – THESE
WILL BE COLLATED & SHARED AFTER THE MEETING.
Professional Groups Table Top Discussions
www.england.nhs.uk
Any Other Business
• Maastricht Approach
• Date of the Next Meeting: 17th
November
• Future Meeting Planning –
ARMS,CAMHS
• Closing Remarks
• Evaluation
Dr Steve Wright, Co-Chair
www.england.nhs.uk
Yorkshire and the Humber
Early Intervention in Psychosis Network
Thank You for Attending!
Don’t forget to fill out your evaluation!
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