key activities of an arms service dr samantha bowe clinical psychologist / clinical lead for edit...
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Key Activities of an ARMS Key Activities of an ARMS ServiceService
Dr Samantha BoweDr Samantha BoweClinical Psychologist / Clinical Lead for EDIT Clinical Psychologist / Clinical Lead for EDIT
ServicesServicesBSTMH NHS TrustBSTMH NHS Trust
AcknowledgementsAcknowledgements
Salford EDIT TeamSalford EDIT Team
Dr Sophie ParkerDr Sophie Parker Maria KaltsiMaria Kaltsi
Clinical PsychologistClinical Psychologist Assistant PsychologistAssistant Psychologist
Rory ByrneRory Byrne Sarah FordSarah Ford
Service User RepresentativeService User Representative Assistant PsychologistAssistant Psychologist
Jane FosterJane Foster
PA/ Team SecretaryPA/ Team Secretary
Dr Paul French / Prof Tony MorrisonDr Paul French / Prof Tony Morrison
Associate Directors in Early InterventionAssociate Directors in Early Intervention
Identification Young People At-Risk Identification Young People At-Risk of Psychosisof Psychosis
Training with potential referrers to help recognise Training with potential referrers to help recognise ‘at-risk’ signs‘at-risk’ signs
Information: attenuated route / BLIPs / family route Information: attenuated route / BLIPs / family route / service delivery / leaflets for client/ service delivery / leaflets for client
Primary Care Checklist for guidancePrimary Care Checklist for guidance Assessment using specific ‘at-risk’ measure e.g. Assessment using specific ‘at-risk’ measure e.g.
CAARMSCAARMS Clear feedback to referrers of outcomeClear feedback to referrers of outcome
If physical signs consider
Substance abuse
Liver function abnormalities
Systemic infection
Nutritional deficiencies
CNS abnormalities
Metabolic disorders
Cardiac abnormalities
Drug toxicity
Primary Care Guidelines for Identification of Suspected or First Episode Psychosis
Checklist for Psychosis Scoring
The family is concernedExcess use of alcoholUse of street drugs (including cannabis)Arguing with friends and familySpending more time alone
………… One point each …………….
Sleep difficultiesPoor appetiteDepressive moodPoor concentrationRestlessnessTension or nervousnessLess pleasure from things
………… Two points each ………….
Feeling people are watching you *Feeling or hearing things that others cannot *
………… Three points each …………
Ideas of reference *Odd beliefs *Odd manner of thinking or speechInappropriate affectOdd behaviour or appearanceFirst degree family history of psychosisplus increased stress or deterioration infunctioning *
………… Five points each …………...
TWENTY POINTS OR MORE CONSIDER
REFERRAL
FOR ASSESSMENT .
____ ____ ____ ____ ____
Sub Total ____
____ ____ ____ ____ ____ ____ ____
Sub Total ____
____ ____
Sub Total ____
____ ____ ____ ____ ____
____
Sub Total ____
Final Total
If any * items areendorsed then considerreferral to EDIT even ifscore is less than 20
19.7.02 19.7.02
EDIT
0161 772 4350
EI team0161 745 2254
CMHT
Crisis Team
If immediate risk
Sub-threshold/uncertaindiagnosis
Clearly first episode psychosis
Referral PathwaysReferral PathwaysReferral SourceReferral Source No. ReferredNo. Referred Community Mental Heath TeamsCommunity Mental Heath Teams
Youth Offending TeamYouth Offending Team
Primary Care Psychology ServicesPrimary Care Psychology Services
General Practitioner (GP)General Practitioner (GP)
Early Intervention TeamEarly Intervention Team
Inpatient UnitInpatient Unit
Housing AgenciesHousing Agencies
ConnexionsConnexions
Crisis TeamCrisis Team
Drug ServicesDrug Services
Self ReferralSelf Referral
FamilyFamily
CAMHSCAMHS
Assertive OutreachAssertive Outreach
2626
1919
1717
77
77
77
66
55
44
44
22
22
22
11
Evidence Based InterventionsEvidence Based Interventions
Preventative approach with developing Preventative approach with developing evidence baseevidence base
Important to draw on evidence base so farImportant to draw on evidence base so far Not automatically replicate existing models Not automatically replicate existing models
& treatments used in mental health (e.g. & treatments used in mental health (e.g. CMHT / EI)CMHT / EI)
Different client group – often younger, not Different client group – often younger, not yet made transition :- ethical issuesyet made transition :- ethical issues
Evidence Based InterventionsEvidence Based Interventions
Cognitive TherapyCognitive Therapy Effective at preventing transition to psychosis Effective at preventing transition to psychosis Transition rates (12 months post CT): cognitive Transition rates (12 months post CT): cognitive
therapy: 6%therapy: 6% monitoring alone: 22%monitoring alone: 22% If no intervention at all: Yung et al. (1998) – 40%@ If no intervention at all: Yung et al. (1998) – 40%@
6mths 6mths Salford EDIT 2006-2007: 8% transition rateSalford EDIT 2006-2007: 8% transition rate Evidence base for psychosis, anxiety, depression Evidence base for psychosis, anxiety, depression
etc. Helpful for false positive group.etc. Helpful for false positive group.
Evidence Based InterventionsEvidence Based Interventions
Collaborative, normalising, individual Collaborative, normalising, individual problem list & goals, formulation to inform problem list & goals, formulation to inform intervention strategies.intervention strategies.
Acceptable intervention for clients: low drop Acceptable intervention for clients: low drop out rate in EDIE Iout rate in EDIE I
Drop Out RatesDrop Out Rates
0
10
20
30
40
50
60
PACE EDIE PRIME
% o
f dr
opou
ts
McGorry et al. 2002
[CBT plus risperidone]
McGlashan et al. 2006
[Olanzapine]
Morrison et al. 2004
[CT]
Case ManagementCase Management
Social difficulties increase risk of psychosis Social difficulties increase risk of psychosis & other mental health problems & other mental health problems
Case management located in EDITCase management located in EDIT Promotes engagementPromotes engagement Assist & promote use of mainstream Assist & promote use of mainstream
services (e.g. housing, benefit agencies, services (e.g. housing, benefit agencies, connexions). Balance help with promoting connexions). Balance help with promoting independence.independence.
Anti-Psychotic MedicationAnti-Psychotic Medication
Lack of evidence base so far Lack of evidence base so far PRIME study: McGlashen et al. (2003)PRIME study: McGlashen et al. (2003) olanzapine 5-15mg a day for 1 year, 12 mth follow olanzapine 5-15mg a day for 1 year, 12 mth follow
upup Transition rates: olanzapine = 16 %Transition rates: olanzapine = 16 % placebo = 37%placebo = 37% Side effects / ethical issuesSide effects / ethical issues If not effective, less compliance if make transition?If not effective, less compliance if make transition? Follow International Clinical Practice Guidelines for Follow International Clinical Practice Guidelines for
Early Psychosis (2005) Early Psychosis (2005)
Anti-Psychotic MedicationAnti-Psychotic Medication
Anti-psychotics not usually indicated unless Anti-psychotics not usually indicated unless person meets criteria for psychosisperson meets criteria for psychosis
Exceptions: severe suicidal risk, rapid Exceptions: severe suicidal risk, rapid deterioration, treatment of depression ineffective, deterioration, treatment of depression ineffective, aggression poses risk to othersaggression poses risk to others
Low dose for trial periodLow dose for trial period EDIT: if prescribed anti-psychotic contact referrer EDIT: if prescribed anti-psychotic contact referrer
to discuss rationale / info. packsto discuss rationale / info. packs Training slot: SPR’s in Trust: info. packs / Training slot: SPR’s in Trust: info. packs /
International Clinical Practice GuidelinesInternational Clinical Practice Guidelines
MonitoringMonitoring
Regularly repeat assessment measures Regularly repeat assessment measures to Ensure effectiveness of interventions & monitor to Ensure effectiveness of interventions & monitor
mental state over timemental state over time Monitoring offered up to 3 years even if not Monitoring offered up to 3 years even if not
engaged with other aspects of serviceengaged with other aspects of service Reduce DUPReduce DUP If at-risk at monitoring appt. – booster sessions / or If at-risk at monitoring appt. – booster sessions / or
increase contactincrease contact Flexible: consent for face to face contact / phone Flexible: consent for face to face contact / phone
or e-mail etc.or e-mail etc.
Duration Of Untreated PsychosisDuration Of Untreated Psychosis
Greater length of time between onset of Greater length of time between onset of psychosis & receiving treatment the worse psychosis & receiving treatment the worse the prognosisthe prognosis
Average DUP 1 year (Barnes et al. 2000)Average DUP 1 year (Barnes et al. 2000) ARMS service can reduce DUPARMS service can reduce DUP EDIT: 25% referred onto to EI with EDIT: 25% referred onto to EI with
undetected first episode psychosisundetected first episode psychosis
Service User InvolvementService User Involvement
Service user feedbackService user feedback EDIT: Service User Representative – EDIT: Service User Representative –
consultancy role on service developmentconsultancy role on service development
- interview panel for recruitment- interview panel for recruitment
- service user forum / research- service user forum / research
- someone clients to speak to when deciding - someone clients to speak to when deciding whether or not to be seen for assessment or whether or not to be seen for assessment or therapytherapy
Interface with ServicesInterface with Services
Ensure effective interface between servicesEnsure effective interface between services e.g. primary care, EI, CMHT’s, voluntary e.g. primary care, EI, CMHT’s, voluntary
sector, A&E, CAMHS etc.sector, A&E, CAMHS etc. Co-working: clear guidelines written into Co-working: clear guidelines written into
protocols (e.g. CAMHS, EI)protocols (e.g. CAMHS, EI) EDIT: primary care, link into established EDIT: primary care, link into established
services when appropriate (e.g. A&E, services when appropriate (e.g. A&E, CMHT’s, EI etc)CMHT’s, EI etc)
Responsive to risk Responsive to risk
Family InvolvementFamily Involvement
Involvement of family / significant others for Involvement of family / significant others for support & advicesupport & advice
With clients consent: regular feedback, With clients consent: regular feedback, psycho education, sharing of formulation, psycho education, sharing of formulation, advice on how best to help, crisis plans / advice on how best to help, crisis plans / emergency no’semergency no’s
Family intervention if appropriateFamily intervention if appropriate
Awareness Raising Awareness Raising
Awareness raising & education about psychosis in Awareness raising & education about psychosis in primary care, social care, voluntary sector, & primary care, social care, voluntary sector, & educationeducation
Mental health promotional work in schools, Mental health promotional work in schools, colleges etc.colleges etc.
De-stigmatise psychosis: challenge De-stigmatise psychosis: challenge misconceptions (increase likelihood of disclosure misconceptions (increase likelihood of disclosure & positive response) & positive response)
EDIT: currently providing staff training on range of EDIT: currently providing staff training on range of mental health problems, not just on early signs of mental health problems, not just on early signs of psychosispsychosis
Core PrinciplesCore Principles
Culture, age & gender sensitiveCulture, age & gender sensitive - 66% clients in EDIT under 21 yrs- 66% clients in EDIT under 21 yrs
Service user & family focusedService user & family focused - collaborative approach, individually tailored, based on clients’ - collaborative approach, individually tailored, based on clients’
‘problem list’ & goals‘problem list’ & goals - family involvement- family involvement
Meaningful engagement based on assertive Meaningful engagement based on assertive outreach modeloutreach model
- home visits, do not discharge due to non attendance, open door - home visits, do not discharge due to non attendance, open door policy, flexible approach: e-mail, text etc. policy, flexible approach: e-mail, text etc.
Core PrinciplesCore Principles Low use of stigmatising settingsLow use of stigmatising settings (youth friendly, age appropriate, primary care settings, (youth friendly, age appropriate, primary care settings,
home visits)home visits) - Fear of going mad common – important to keep in - Fear of going mad common – important to keep in
primary care (if see within a MDT setting: can be primary care (if see within a MDT setting: can be frightening, increase distress, effect engagement)frightening, increase distress, effect engagement)
- Service delivery in primary care setting (EDIT & GP) - Service delivery in primary care setting (EDIT & GP) unless significant risk issues which require co-working with unless significant risk issues which require co-working with other servicesother services
Recovery based principles: Recovery based principles: - - meaningful activitiesmeaningful activities - valid social roles (college, work, relationships)- valid social roles (college, work, relationships)
Summary: Core FeaturesSummary: Core Features
Raise Awareness /
EducationStigma
Reduce DUP
Prevent Transition to
Psychosis
ARMS Service
Summary: Core FeaturesSummary: Core Features
Family Involvement
Case Management
MonitoringUp to 3 years
Evidence Based
Interventions
Specialist Assessment
ARMS client
Summary: Core FeaturesSummary: Core Features
Primary Care Setting
Good Interface with
Other Services
Recovery Focused
PIGCompliant
ARMS Service
Service User QuotesService User Quotes
““Like this psychology session, I mean if I had to go Like this psychology session, I mean if I had to go out and come to see everybody, the psychologist out and come to see everybody, the psychologist and things like that, I wouldn’t go out of the house and things like that, I wouldn’t go out of the house and that’s why I never got no where for years, but and that’s why I never got no where for years, but when the counsellor did get me in touch with the when the counsellor did get me in touch with the psychologist, I knew I’d stick with them because psychologist, I knew I’d stick with them because they’d do home visits, because I don’t go out and I they’d do home visits, because I don’t go out and I need help, but I need someone to come to me need help, but I need someone to come to me because I can’t do it”. because I can’t do it”.
Service User QuotesService User Quotes
‘‘like a dark cloud over your head, you can’t even like a dark cloud over your head, you can’t even sleep at night, just there thinking someone is going sleep at night, just there thinking someone is going to come, I thought I was in a movie, I’m dreaming, to come, I thought I was in a movie, I’m dreaming, but it’s not a dream’ but it’s not a dream’
‘‘well, before I started to cut meself I’d think, “god, well, before I started to cut meself I’d think, “god, they’re just doing it for attention” but until you are they’re just doing it for attention” but until you are actually in that situation you don’t understand what actually in that situation you don’t understand what they are going through …you understand more they are going through …you understand more then. You look at it in a different way’then. You look at it in a different way’
Service User QuotesService User Quotes
‘‘if you have someone like that to talk to it’s a lot more if you have someone like that to talk to it’s a lot more helpful than if you don’t helpful than if you don’t because if you don’t you’re just because if you don’t you’re just thinking you’re going really mad’thinking you’re going really mad’
‘‘basically you’re just going over the same thought, you’re basically you’re just going over the same thought, you’re going “am I crazy?” and going “am I crazy?” and then you’re going “well, I’m not” then you’re going “well, I’m not” and it’s just a big circle and then you’re conflicting and it’s just a big circle and then you’re conflicting with with yourself but if you have someone there they can explain, yourself but if you have someone there they can explain, like you say it to like you say it to them, they come back with a different them, they come back with a different answer, they don’t come back with the same answer, they don’t come back with the same one that one that you think all the time and it changes the circle, it changes you think all the time and it changes the circle, it changes the pattern’the pattern’
Service User QuotesService User Quotes
‘‘yeah, I was like bubbly and confident and not shy and stuff yeah, I was like bubbly and confident and not shy and stuff like that. Because like that. Because when I started to first cut meself I was when I started to first cut meself I was losing all me confidence when I was losing all me confidence when I was depressed and I depressed and I didn’t want to go out, I didn’t want to do me hair, I just didn’t want to go out, I didn’t want to do me hair, I just wanted to wanted to stay in bed all day and that was when I kept stay in bed all day and that was when I kept on cutting meself and then like I’d been on cutting meself and then like I’d been on anti on anti depressants for a bit, (therapist) came here a few times, depressants for a bit, (therapist) came here a few times, spoke to her, it was spoke to her, it was just all coming back, all me confidence just all coming back, all me confidence coming back, just getting back to normal, how I used to be coming back, just getting back to normal, how I used to be like before, y’know before it all started,’like before, y’know before it all started,’
‘‘I’m proud of myself, I’m very proud of myself, oh my God, I’m proud of myself, I’m very proud of myself, oh my God, I’ve done good, it’s not easy, you know that’I’ve done good, it’s not easy, you know that’
ReferencesReferences
Parker, S., French, P., Kilcommons, A., & Shiers, D. Parker, S., French, P., Kilcommons, A., & Shiers, D. (2007). Report on Early Detection and Intervention for (2007). Report on Early Detection and Intervention for Young People at Risk of Psychosis.Young People at Risk of Psychosis.
Parker, S. & French, P. (2007). Implementation Guide.Parker, S. & French, P. (2007). Implementation Guide.
Hardy, K. & Morrison, A. P. 2007. The journey into and Hardy, K. & Morrison, A. P. 2007. The journey into and through EDIT - a qualitative exploration of the experiences through EDIT - a qualitative exploration of the experiences of our clients. Unpublished Doctorate Thesis. University of of our clients. Unpublished Doctorate Thesis. University of Liverpool.Liverpool.
Contact DetailsContact Details
[email protected]@bstmht.nhs.uk
Dr Samantha BoweDr Samantha Bowe
Clinical Psychologist / Clinical Lead for EDIT ServicesClinical Psychologist / Clinical Lead for EDIT Services
0161 772 43500161 772 4350