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Aims and Method
To investigate the effects of a standard National Health Service early intervention in psychosis service on bed days and engagement with services. We conducted a naturalistic before-and-after study comparing outcomes of individuals who received treatment from the service ( n =75) with outcomes of individuals who presented to mental...
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Citations
... There is sustained interest in increasing access to EIP services for people of all ages who develop a first episode of psychosis, and a clear need to prevent disengagement. Engagement with EIP services leads to increased service user satisfaction, fewer symptoms, relapses and hospital admissions, better health, wellbeing, social and occupational function and fewer suicides [12,[38][39][40][41] in the medium to long term [17][18][19][20]38]. Disengagement of young people with psychosis represents a significant cost to their health and wellbeing and impacts on families, society and the NHS. ...
Background
Early Intervention in Psychosis (EIP) services improve health outcomes for young people with psychosis in the medium–long term, but 25% of young people disengage in the first 12 months with costs to their mental health, families, society and the NHS. This study will evaluate the effectiveness, cost-effectiveness and implementation of a team-based motivational Early Youth Engagement (EYE-2) intervention.
Method
The study design is a cluster randomised controlled trial (RCT) with economic evaluation, comparing the EYE-2 intervention + standardised EIP service to standardised EIP service alone, with randomisation at the team level. A process evaluation will evaluate the delivery of the intervention qualitatively and quantitatively across contexts.
The setting is 20 EIP teams in 5 sites: Manchester, South London, East Anglia, Thames Valley and Hampshire. Participants are young people (14–35 years) with first episode psychosis, and EIP staff.
The intervention is the team-based motivational engagement (EYE-2) intervention, delivered alongside standardised EIP services, and supported by additional training, website, booklets and social groups. The comparator is the standardised EIP service. Both interventions are delivered by EIP clinicians.
The primary outcome is time to disengagement (time in days from date of allocation to care coordinator to date of last contact following refusal to engage with EIP service, or lack of response to EIP contact for a consecutive 3-month period). Secondary outcomes include mental and physical health, deaths, social and occupational function, recovery, satisfaction and service use at 6, 12, 18 and 24 months.
A 12-month within-trial economic evaluation will investigate cost-effectiveness from a societal perspective and from an NHS perspective.
Discussion
The trial will provide the first test of an engagement intervention in standardised care, with the potential for significant impact on the mental health and wellbeing of young people and their families, and economic benefits for services. The intervention will be highly scalable, supported by the toolkit including manuals, commissioning guide, training and resources, adapted to meet the needs of the diverse EIP population, and based on an in-depth process evaluation.
Trial registration
ISRCTN 51629746 prospectively registered 7th May 2019. Date assigned 10th May 2019.
... Full details of the individual studies can be found in Table 1. Two studies used retrospective case data to compare service models (Dodgson et al., 2008;Fowler et al., 2009); one was a cross-sectional case control study comparing two EIT service models (Cheng et al., 2014); and two were naturalistic service evaluations (Burbach et al., 2009;Mantas & Mavreas, 2012). Comparisons between studies are not possible due to different outcome measures being used, differences in geographical, population and health service factors and lack of reported specificity of what interventions are provided. ...
... Kingdom-based evaluation studies demonstrated positive outcomes for use of hub-and-spoke EIT (Burbach et al., 2009) with one demonstrating favourable outcomes over a standard community mental health team (Dodgson et al., 2008). An evaluation study in Greece further demonstrated positive outcomes for a hub-and-spoke model (Mantas & Mavreas, 2012). ...
Aim
Early Intervention in Psychosis teams (EITs) are a growing entity internationally, yet they remain under‐researched given challenges facing their delivery. Model adaptations include stand‐alone services, a hub‐and‐spoke model with various bases and integrating specialist staff into existing mental health teams. The present critical review focuses on reviewing the evidence base for the delivery of EITs in rural areas, first pertaining to evidence for model adherence and second to clinically outcomes.
Method
A systematic literature search was undertaken, finding 53 papers of interest. Nine papers met the inclusion criteria. A critical appraisal tool was used to consider the quality of the evidence and a narrative review of their findings is presented.
Results
The five studies reporting clinical outcomes of rural EITs demonstrate positive outcomes of a hub‐and‐spoke and stand‐alone EIT on reducing hospital admissions, psychotic symptoms and improving quality of life. One study directly comparing hub‐and‐spoke to stand‐alone EIT found that hub‐and‐spoke EIT had more positive outcomes than a stand‐alone service. Of the studies attempting to promote adherence to EIT model in rural areas, services show low overall adherence and report issues pertaining to funding and managerial support for practical barriers to implementation.
Conclusions
EIT services in rural areas may show similar positive outcomes to urban areas and adaptations to suit rural populations appear acceptable, such as using a hub‐and‐spoke model, though further research is required. Adherence to EIT service models in rural areas may be limited and training programmes to promote adherence benefit from managerial and financial support.
... 37 Vzhledem k tomu se tak jeví jako optimální forma fungování týmů včasných intervencí hub-and-spoke model, tedy uspořádání, kdy je malý tým, který se věnuje výlučně včasné detekci a včasným intervencím, součástí většího komunitního týmu. 27,38 Nabízí se tedy možnost zavedení specializovaných týmů včasné detekce a včasné intervence jakožto subtýmů Center duševního zdraví. Toto uspořádání by rovněž bylo vhodné s ohledem na destigmatizační aktivity, která jsou pro včasnou detekci osob v raných fázích závažných duševních onemocnění klíčové. ...
Introduction: Specialized services for people in early stages of serious mental illness have positive effect on quality of life, general prognosis of the illness and on long-term costs of mental health system.
Objective: The aim of the paper is to analyse care being provided by community social care services for clients in early stages of serious mental illness in the Czech Republic.
Method: 28 semi-structured interviews with community service providers for people with serious mental illness were conducted. Interviews were focused on methods of interventions for people with serious mental illness and on accessible capacities of care network for the target group. Interviews were analysed qualitatively using thematic analysis. Results: Hospitalization in psychiatric hospital is usually the first contact with mental health services for people in early stages of serious mental illness. Minority of these people is contacted by community social services, although the services struggle with insufficient capacities for work with this target group. Insufficient cooperation with other relevant stakeholders, especially schools and general practitioners, and limited public knowledge about mental illnesses are the barriers for better early detection and early intervention.
Discussion: Network of specialized care for people in early stages of serious mental illness is missing in the Czech Republic. Care for this target group is delivered late and most often through hospitalization. Community social services provide interventions similar to those being provided in specialized programmes for people in early stages of serious mental illness abroad. However, due to limited capacities, insufficient network of community services and lack of standardized manuals for this target group it is necessary to continuously develop services for people in early stages of serious mental illness. In context of ongoing psychiatric reform these specialized services could be prospectively implemented into evolving Mental Health Centres.
... This study highlights the use and relevance of routine outcome measures and administrative data sets in demonstrating the benefits of care delivered. EP services have been associated with considerable reduction in the rate and duration of MH inpatient admissions during treatment when compared with standard care (Craig et al., 2004;Dodgson et al., 2008;Dodgson, Ross, Tiffin, Mitford, & Brabban, 2012;McGorry, Edwards, Mihalopoulos, Harrigan, & Jackson, 1996;Petersen et al., 2005). In addition, these improvements are maintained at follow-up (Chan et al., 2015;Craig et al., 2004;Dodgson et al., 2012). ...
Aim
This study aimed to introduce a set of administrative key performance indicators (KPIs) for Early Psychosis Services.
Methods
The study design was longitudinal with data retrieved from a 4‐year period between January 2009 and December 2013 included in the study. Descriptive statistics and t tests were used to evaluate the KPIs.
Results
Results in the 1 year before early psychosis (EP) intervention and 1‐year postintervention were calculated for most items, and entry and exit scores were calculated for involuntary treatment orders (ITOs) and Health of the Nation Outcome Scale (HoNOS) scores. There was a 54% reduction in mental health emergency department presentations representing a cost saving of $62 524.00 (AUD). There was also an improvement in the number and duration of mental health admissions with a financial saving of $1 653 534.00 (AUD). Patients improved on all HoNOS scores from entry to exit from the services. ITOs were reduced by approximately 29% on discharge from the service.
Conclusions
Administrative data can provide useful KPIs to measure the effectiveness of EP teams and allow benchmarking with similar services.
... Family members are often involved in the treatment process in order to increase their awareness and ability to cope with and respond to the symptoms of the patient. Previous research has provided evidence that these programs are effective at improving symptoms and prognosis [4,7,[10][11][12][13][14]. Lack of medication adherence among those with psychotic disorders is associated with poorer outcomes [15][16][17]. ...
Background
Assertive community treatment for first-episode psychosis programs have been shown to improve symptoms and reduce service use. There is little or no evidence on whether these programs can increase access to income assistance and improve medication adherence in first episode psychosis patients. This research examines the impact of the Early Psychosis Prevention and Intervention Service (EPPIS) on these outcomes.
Methods
We extracted data on EPPIS patients held in the Data Repository at the Manitoba Centre for Health Policy. The Repository is a comprehensive collection of person-level de-identified administrative records, including data from Manitoba’s health services. We compared income assistance use and antipsychotic medication adherence in EPPIS patients to a historical cohort matched on pattern of diagnosis. Confounders were adjusted through propensity-score weighting with asymmetrical trimming. Odds ratios (OR), hazard ratios (HR) and 95% confidence intervals were calculated.
Results
We identified a matched sample of 244 patients and 449 controls. EPPIS patients had a higher rate of income assistance use during the program (67·4% vs. 38·7%; p< 0·0001). EPPIS patients were more likely to have been prescribed at least one antipsychotic medication than the control cohort, both during the program (OR = 15·05; 95%CI 10·81 to 20·94) and after the program ended (OR = 5·20; 95%CI: 4·50 to 6·02). Patients in EPPIS were also more likely to adhere to their medication during the program (OR = 4·71; 95%CI 3·75 to 5·92), and after the program (OR = 2·54; 95%CI 2·04 to 3·16).
Conclusion
Enrolment in the EPPIS program was associated with increased adherence to antipsychotic medication treatment and improved uptake of income assistance.
... These studies show some limited effect in improving admission, readmission rates, vocational recovery and quality of life criteria in comparison to historical community mental health care as usual controls. 19,20 Criticisms of this model include limited multidisciplinary presence within CMHTs, limited specialist input from psychiatry and psychology, potential isolation of the 'spokes' and a falling off of specialist knowledge and ethos. 21 The phase-specific interventions may not include employment or a retraining focus, and the interventions may not be specifically EI focused. ...
... Table 1 provides a summary of the final studies included, and Table 2 provides a description of the outcomes and quality indicators of the studies. To summarize the final studies included, there were seven peer-reviewed publications 19,20,[26][27][28][29][30] and two conference papers. 31,32 Although the majority of publications in this area come from the UK and Australia, there are also publications from Europe, the US and Canada. ...
... One from the UK evaluated the 'Hub and Spoke' model in comparison with treatment as usual and one from Canada evaluated 'Hub and Spoke' in comparison with specialist outreach. 19 There are two recent cluster RCTs from the USA and Italy evaluating EI integrated within CMHT care in comparison with treatment as usual. 30 These show improvements in quality of life and positive symptoms, although the Italian study had a very short follow-up period of 9 months. ...
Aim:
Although early intervention in psychosis is an accepted policy internationally, the evidence base for this paradigm, originates mostly from the specialist model. In a real world setting, variations of this model are often implemented. The aim of this paper is to systematically evaluate the evidence for delivering early intervention outside the specialist stand-alone centre.
Methods:
A systematic search following the PRISMA guidelines was undertaken in Medline, PsycInfo, Embase and the Cochrane trials register. The search was limited to articles in English from 1990 to end of January 2016. Inclusion criteria for the review comprised comparative evaluations of services delivering early intervention in psychosis outside the specialist model. Exclusion criteria included prodromal services, descriptions of services without reference to a comparator and stand-alone specialist services evaluated in comparison to treatment as usual.
Results:
There were 637 unique citations. Twenty-eight papers were reviewed at second-stage screening. The majority were excluded as they compared specialist early intervention with treatment as usual, did not evaluate the first episode or had no comparator. Seven peer-reviewed publications and two conference papers fulfilled criteria evaluating models of delivering early intervention other than the specialist model.
Conclusions:
There is a spaucity of evidence evaluating models other than specialist models in early intervention. Published studies are heterogeneous in design and outcome. Although there have been two recent trials evaluating integrated early intervention in comparison with treatment as usual, it remains unclear whether reported improved outcomes of specialist centres apply to other models.
... Details for the included studies are located in Table 1 (additional details found in supplementary table 1). Most of the studies were conducted in commonwealth countries; the United Kingdom (5), 9,20,[25][26][27] Australia (3), 21,23,28,29 and Canada (1). 30 Scandinavian countries produced 4 of the studies; Sweden (2), 18,31 Denmark (1), 11 and Norway (1). 32 The remaining 2 were in Italy and Hong Kong. ...
... The assertiveness of the programs may have reduced inpatient use by increasing adherence to treatment and continuity of care for patients in the community. 19,25 Perhaps the simplest explanation of this effect is that these services simply increase the availability of treatment in the community and therefore reduce the need to rely on inpatient units for treatment. ...
Objectives: To review and synthesize the currently available research on whether early intervention for psychosis programs reduce the use of inpatient services. Methods: A systematic review was conducted using keywords searches on PubMed, Embase (Ovid), PsycINFO (ProQuest), Scopus, CINAHL (EBSCO), Social Work Abstracts (EBSCO), Social Science Citations Index (Web of Science), Sociological Abstracts (ProQuest), and Child Development & Adolescent Studies (EBSCO). To be included, studies had to be peer-reviewed publications in English, examining early intervention programs using a variant of assertive community treatment, with a control/comparison group, and reporting inpatient service use outcomes. The primary outcome extracted number hospitalized and total N. Secondary outcome extracted means and standard deviations. Data were pooled using random effects models. Primary outcome was the occurrence of any hospitalization during treatment. A secondary outcome was the average bed-days used during treatment period. Results: Fifteen projects were identified and included in the study. Results of meta-analysis supported the occurrence of a positive effect for intervention for both outcome measures (any hospitalization OR: 0.33; 95% CI 0.18-0.63, bed-days usage SMD: -0.38, 95% CI -0.53 to -0.24). There was significant heterogeneity of effect across the studies. This heterogeneity is due to a handful of studies with unusually positive responses. Conclusion: These results suggest that early intervention programs are superior to standard of care, with respect to reducing inpatient service usage. Wider use of these programs may prevent the occurrence of admission for patients experiencing the onset of psychotic symptoms.
© The Author 2015. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.
... [20][21][22][23] Studies have shown that alternative models can deliver the complement of services that constitute EPI, with positive results. [23][24][25] Embedded approaches are often used in rural areas where a central specialist team may be difficult to staff and challenging for clients to access. [26][27][28] However, research on effective rural delivery is limited, 29,30 and national surveys of EPI implementation have reported lower levels of compliance with EPI standards in rural and poorer areas. ...
AimOntario, Canada is a large province with a geographically dispersed population. Early psychosis intervention (EPI) programmes are available province-wide, with delivery approaches adapted to context. This study examined EPI programme delivery in relation to recently released provincial EPI Program Standards, and variations based on geographic context.Methods
The data source was a province-wide key informant survey of early psychosis programmes conducted after release of the Standards. Chi-squared tests compared large- and small-area programmes on selected programme structural features and perceived adherence to 19 service components.ResultsResponses were obtained from 52 programme sites, including 21 small-area programmes with 1 to 2 staff. In general, frequency of EPI delivery was highest for individual assessment and treatment components, and moderate for social supports and family support. Implementation was lowest for public education, early detection and recovery planning. Small-area programmes reported lower implementation for over half of the components, with differences statistically significant for psychiatric assessment and physical health monitoring.Conclusion
Since the release of the Standards, the Ontario Ministry of Health has partnered with a provincial network of EPI stakeholders to support practice improvement. This survey identified components where more implementation support is needed, overall and for rural area delivery. Ultimately, systematic monitoring of programme fidelity and measuring client outcomes are key to advancing the quality of EPI programme delivery.
... El National Health Service británico amplió las competencias y la respon sabilidad profesional del cuerpo de enfermería de forma que la mayoría de los equipos especializados están gestionados y compuestos, casi exclusiva mente, por personal de enfermería de salud mental y en ellos los psiquiatras juegan el papel de consultores expertos. Los equipos de intervención tem prana en psicosis han sido objeto de atención intensiva recientemente [94][95][96][97][98][99] . Si bien su eficacia para reducir los reingresos y el tiempo de estancia en el hospital y, en consecuencia, reducir gastos sanitarios no se pone en duda, así como para mejorar la accesibilidad, la continuidad asistencial y la satisfac ción de los usuarios y familiares a corto plazo, sin embargo algunas de las ventajas clínicas pueden no mantenerse a largo plazo 99 . ...
... Los equipos de intervención tem prana en psicosis han sido objeto de atención intensiva recientemente [94][95][96][97][98][99] . Si bien su eficacia para reducir los reingresos y el tiempo de estancia en el hospital y, en consecuencia, reducir gastos sanitarios no se pone en duda, así como para mejorar la accesibilidad, la continuidad asistencial y la satisfac ción de los usuarios y familiares a corto plazo, sin embargo algunas de las ventajas clínicas pueden no mantenerse a largo plazo 99 . ...
Objective:
To assess the comprehensive care program for the mentally ill in prison (PAIEM), which has been implemented for 3 years in Spanish prisons with the aim of improving processes and results.
Methods:
Descriptive study of the data gathered from an anonymous questionnaire completed by members of the PAIEM team in prisons. Frequency distributions were obtained of all the variables relating to facts, attitudes, opinions, experiences, situations and processes of the PAIEM.
Results:
91.2% of the PAIEM teams responded. Psychologists, educators, doctors and social workers were the professionals that collaborated most actively in the PAIEM (73%-84%) and were the ones to act most frequently as tutors. The mentally ill are usually located in ordinary modules (80%). The most commonly used activities for their psycho-social rehabilitation are self care (73%), education for health, preparation for daily life and social skills (more than 60%). Interventions with families are basically by telephone (79%). Bivariate analysis showed that the PAIEMs that operate most effectively are those that coordinate well with other technical teams, that prepare referral more than six months prior to release and ones where the NGOs process the referrals. Over 71% of the professionals observed improvements of disabilities and needs in over half the patients more than half of the professionals involved are satisfied (3.4/5) with their participation, although they acknowledge that there is a greater work load.
Conclusions:
The activities of the PAIEM are adequate, especially in the phases of early detection, stabilisation and rehabilitation and less so in the social incorporation phase, which improves when the third sector intervenes in referrals of patients to the social health care network outside prison.
... The fragmentation of the U.S. health care system poses particular challenges for FEP and early-intervention programs. Many implementation and financing strategies are possible (5), such as using fully or partially dedicated FEP teams, training a team of clinicians with other responsibilities to provide FEP treatment as needed to their clients, and using a hub-and-spoke model in which practitioners trained in FEP treatment travel to clients in a designated area (6). However, it is unlikely that a single payer will support the comprehensive activities called for in FEP programs, and coordination across systems of care can be difficult. ...
The New York State Office of Mental Health (OMH), which is a partner in the RAISE (Recovery After Initial Schizophrenia Episode) Connection program, is scaling up services for individuals with first-episode psychosis (FEP) and must estimate the number of specialized treatment teams needed across the state. This column describes a modeling tool that allows users to input various estimates for relevant variables and see the impact on projections for number of FEP teams needed and the costs of those teams. The interactive, Excel-based tool can be adapted for other treatment settings and programs.
