early care around the world, and closer to home: review
TRANSCRIPT
Early Episode Psychosis Care Around the World, and Closer to Home: Review of the Evidence Base and
Best PracticesIrene Hurford, M.D.
Program Director, PEACE Program, Horizon HouseAssistant Professor, Department of Psychiatry,
University of Pennsylvania
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John
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Consequences of prolonged DUP
Early Detection• Treatment and Intervention
in Psychosis (TIPS) ‐ 10 year outcomes
• Reduced DUP from 16 wksto 5 wks
• Currently DUP in the US averages between 1‐3 years.
• WHO guidelines recommend DUP < 3 months
Hegelstad WT et al. Am J Psychiatry 2012;169(4):374‐380
OR 2.5
OR 0.5
OR 3.1
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Early Intervention Around the Globe
1992 TIPS Norway
1996EPPIC Australia
1998 OPUSNetherlands/IEPA
2001UK National Health Priority
2004 WHO Guidelines
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Patrick McGorry, Australian of the Year 2010
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Countries with Early Episode Programs
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The U.S. Joins the Party!
2001PIER/EASA
2001PIER/EASA
2004CA Prop
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2004CA Prop
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2007EDIPPP2007EDIPPP
2012NIMH RAISE
2012NIMH RAISE
2013On Track
NY
2013On Track
NY
20145% Set‐Aside
20145% Set‐Aside
2016 Federal Budget doublesset‐aside to 10%
2016 Federal Budget doublesset‐aside to 10%
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Do Early Intervention Programs Work?
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Clinical Benefits
•Symptoms improve in active intensive treatment , but effects appear to dissipate after intensive treatmentdiscontinuation
OPUS 5 Year Follow‐up Data
Bertelsen M, Arch Gen Psychiatry 20089
Functional Benefits
051015202530
Year 1‐2 Year 3‐5
# of Fewer Hospitalization Days
Hospitalization Days
OPUS Trial
At 5 years:• More intervention subjects living independently• Fewer intervention subjects using supported housing
At 10 years, all intervention gains had been lost10
RAISE Connection Study
05101520253035404550
% Improvement
GAF OccupationalGAF SocialPANSS Total
Percent Improvement on Symptom and Functional Measures after 24 Months of Intervention
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RAISE Connection Study
0%
20%
40%
60%
80%
100%
BaselineSchool/Employment Rate
24 MonthSchool/Employment Rate
Rates of engagement in school or work at baseline and 24 months of intervention
Dixon L, et al.; Psychiatric Services 2015 12
From: Comprehensive Versus Usual Community Care for First‐Episode Psychosis: 2‐Year Outcomes From the NIMH RAISE Early Treatment Program
American Journal of Psychiatry
c Treatment by square root of time interaction, p=0.016.
Copyright © American Psychiatric Association. All rights reserved.
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Coordinated Specialty Care (CSC) Elements
• Low staff to participant ratio (10:1)• Community Outreach and Engagement• Case Management• Evidence‐based psychotherapy• Family Therapy/ Family Psychoeducation• Supported Employment/Education• Evidence‐Based Psychopharmacology• Coordination with primary care and substance abuse treatment programs
Cost‐Effectiveness Data
• EPPIC Per Annum– EIP patients cost $3588 vs. $9896 for control patients
Mihalopoulos C. et al. Schiz Bull 2009 15
Cost‐Effectiveness Data• Hong Kong EASY Trial:
– 32% less inpatient service– $14,538 vs. $19,681
Wong K K et al. Aust N Z J Psychiatry 2011;45:673-680 16
Cost‐Effectiveness Data
Hastrup L H et al. BJP 2013;202:35-41
©2013 by The Royal College of Psychiatrists
OPUS TrialTotal cost differences = $170,683 for OPUS; $205,138 for TAU (NS)
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Cost‐effectiveness of preventing first‐episode psychosis in ultra‐high‐risk subjects
Ising et al., Psychological Medicine, 2014 18
Take Home Messages
• Early Intervention Programs– Reduce symptoms and improve functioning and quality of life during active intervention, and for ≈ 2‐3 years post‐intervention
– Are probably cost‐effective, and certainly cost‐neutral
– Have not yet proven to be disease‐modifying
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PEACEObjectives
• Significantly shorten the duration of untreated psychosis for participants from an average of 1‐3 years (nationally) to 3 months or less (WHO guidelines)
• Promote successful recovery of participants through– Symptom reduction and functional improvement– Promotion of community integration– Reducing the use of high cost acute services
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PEACE Mission
Keep people with early signs of psychosis on their normal life paths by
• Building community awareness• Offering easily accessible, effective treatment and support with a focus of resiliency and recovery
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PEACE
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PEACE
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PEACE Team
• Program Director/Psychiatrist• Program Coordinator• Resilience and Empowerment Professionals (REPs)
• Certified Peer Specialist• Occupational Therapist• Supported Employment/Supported Education Specialists
• Nurse• Fellows, Residents, Medical Students, SW Interns
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PEACE Elements
• Community Outreach and Engagement• Screening and Assessment• CBT/Case Management• Family Therapy/Multi‐Family Group Psychoeducation• Supported Employment/Education• Occupational Therapy• Certified Peer Specialist• Evidence‐Based Psychopharmacology• Coordination with inpatient services and substance abuse treatment programs
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PEACEDiagnostic Eligibility
• Experiencing, or at risk for, early psychosis (psychosis lasting one year or less from when the threshold symptoms began)
• DSM 5 psychotic spectrum disorders AND those in the prodromal (at‐risk) stage.
• age 15 and older (there is no maximum age cap)
• who have Medicaid or are MA eligible
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Early data
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Cumulative number of Referrals to PEACE
0
20
40
60
80
100
120
140
160
180
0 10 20 30 40 50
# referrals cumulative# pts cumulative
As of 4/6/16 32
Demographic DataNumber %
N 43Mean age 20Median age 20
Male 33 74
African American 34 79
White 3 7Southeast Asian 3 7
Hispanic 3 7
As of 4/1/16 33
Diagnostic CharacteristicsDiagnosis %
Schizophrenia 43
Schizoaffective D/O 18Psychosis NOS 25
Schizophreniform D/O 5
Substance Induced 7
Co‐morbid Trauma History 79As of 4/1/16
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Family Psychosocial Stressors
0%10%20%30%40%50%60%70%80%90%
Singleparentfamily
Relativewith SMI
UncertainHousing
SubstanceAbuse inParent
DHSinvolvement
81%
58%
33%26%
19%
As of 4/1/1635
Baseline and Current Substance Abuse
0%10%20%30%40%50%60%
Baseline SubstanceAbuse
Current Substance Abuse
58%
21%
Substance Abuse Among Participants
As of 4/1/1636
Hospitalizations before and since PEACE
0
10
20
30
40
50
60
# hosps in year prior toPEACE # hosps since PEACE
52
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As of 4/1/1637
Engagement in Outpatient Treatment Prior to PEACE and at PEACE
0%
20%
40%
60%
80%
100%
Engaged Prior to PEACE Engaged at PEACE
26%
93%
As of 4/1/16 38
Growth in Functional ActivitiesAges Over 18
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Enrolled inschool
AttendingSchool
Employed Engaged inSE
Any
IntakeCurrent
As of 4/1/16 39
Growth in Functional ActivitiesAges 18 and Under
0%10%20%30%40%50%60%70%80%90%100%
Enrolled inschool
AttendingSchool
Employed Engaged inSE
Any
IntakeCurrent
As of 4/1/16 40
First Episode Psychosis Programs in PA
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John
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