Reduce DUP and then Treat Well

Australian and Ireland services

Dr Brian O’Donoghue
Clinical Research Fellow –
Reduce DUP and Treat Well

Disclosures

─ No disclosures
Reduce DUP and Treat Well

Outline

─ Rationale for reducing DUP

─ Australian service (EPPIC)
─ EPPIC model
─ Campaigns to reduce delays
─ National roll out
─ Irish service (DETECT)
─ Campaigns to reduce delays
─ Treatments
─ National roll out
 Reduce DUP and Treat Well
Duration of Untreated Psychosis
Help Seeking Delays
Time from onset of symptoms to seeking help
Longer delays associated with:
Poor knowledge about psychosis
Family not involved
Negative symptoms
Poor premorbid functioning
Male gender
Health Service Delays
Time from service contact to treatment
Not recognizing psychotic
symptoms at first contact
Delays to assessment
Delays to diagnosis or treatment
Delays within mental health
services
Reduce DUP and Treat Well

Reduction of DUP
Reduce DUP and Treat Well

Development of Early Intervention for Psychosis in Australia

─ 1988 - Dedicated Youth Psychosis ward at

Aubrey Lew Unit
─ 1992 – EPPIC established - Focus moved
to the community and catchment area
increased to 800,000. 24 hour crisis care,
community care and research
─ 1995 – PACE Clinic – ‘at risk’ for psychosis
─ 1996 - 1st International conference on
Early Psychosis
Reduce DUP and Treat Well

EPPIC – Early Intervention for Psychosis in Australia

Reduce DUP and Treat Well

Reduce DUP - EPPIC Community education campaign

─ 1996 - segment of the EPPIC catchment area was targeted

─ Educational campaign for schools, GPs & Youth workers
─ Intervention group median DUP = 2 months vs control 3
months
─ More cases with a very long DUP (> 3 years) in intervention
─ When cases with a very long DUP were excluded – the
difference neared significance (p=0.06)
Reduce DUP and Treat Well

Reduce DUP - EPPIC Community education campaign

─ Community Development team

─ Strengthen the capacity of individuals and organisations to
understand, identify and respond to the mental health needs
of young people
─ Youth workers, schools, GP, organisations in contact with young
people
Reduce DUP and Treat Well

Reduce DUP - EPPIC Community education campaign

─ TIPS early intervention reduced the DUP to a median of 5

weeks with an intensive educational campaign
─ Joa et al (2008) demonstrated that when the campaign
ceased, the DUP increased to 15 weeks and they detected
less cases
─ The cases that were detected had more severe positive and
negative symptoms
Reduce DUP and Treat Well

Reduce DUP - EPPIC Community education campaign

─ 318 FEP cases 1989 – 1997 (Harris et al 2005)

─ Median DUP = 6 weeks
─ 8 year follow-up: Shorter DUP associated with:
─ Less positive symptoms
─ Enhanced social & occupational functioning, higher QoL

─ 636 FEP cases 1998 – 2000 (Schimmelmann et al 2008)

─ Median DUP = 8 .7 weeks
─ 18 month follow-up: Longer DUP associated with:
─ lower rate of remission of positive symptoms
─ lower employment & functioning
─ higher substance misuse
Reduce DUP and Treat Well

Reduce DUP - Ultra-high risk for psychosis

─ Personalised Assessment Clinic and Evaluation (PACE)

─ First clinical and research service for youth identified
as being at Ultra-High Risk for psychosis - 1995
─ Attenuated psychotic symptoms
─ Brief Limited Intermittent Psychosis
─ First degree family history & low functioning
─ Initially transition rate of 35% in 1 year observed
─ Evaluating interventions to reduce risk of transition
─ Short DUP if transition to psychosis
Reduce DUP and Treat Well

Reduce DUP - EPPIC Rapid Assessment

─ Triage/ Intake
─ 24 hours/ day – 7 days a week
─ Can receive referrals from anyone
─ Categorized as urgent vs routine
─ Assessment & crisis intervention
─ ‘Youth Access Team’ – flexible approach
─ Home based vs clinic based – satellite clinics
─ Youth specific inpatient care
─ Continuing-Care case management
─ 2 year period of care
─ Engagement is crucial
Reduce DUP and Treat Well

Treat well - EPPIC – Medical management

─ Assessment – by mental health clinician & doctor

─ Investigations –
─ physical health screen
─ Haematological & neuroimaging
─ Medication - 48 hour period of assessment
─ Benzodiazepine use in early phase
─ Antipsychotic medication principles
─ Take side-effects into consideration
─ ‘Start low, go slow’
─ Avoid polypharmacy
Reduce DUP and Treat Well

Treat well - EPPIC – Medical management

Reduce DUP and Treat Well

Treat well - EPPIC – Recovery

─ Psychological therapies
─ Cognitive behavioural case management
─ Motivational interviewing
─ Mindfulness
─ Trial - Trauma informed Psychotherapy for Psychosis (TRIPP)

─ Family work

─ Group Program
─ Gym groups
─ Music groups
─ Café culture (barista training)
─ Horticulture
Reduce DUP and Treat Well

Treat well - EPPIC – Recovery

─ Vocational recovery
─ Vocational consultant within clinical service
─ Individual Placement and Support (IPS)
─ Pilot study in 2008
─ Full trial completed in 2014
─ total 146 participants
─ At 18 months - > 80% in IPS group in education or employment
─ >75% in TAU group!

─ Moderated Online Social Therapy

─ Social media and mobile based interventions
─ Aim for long-term social and functional recovery
─ Prevent relapse
 Reduce DUP and Treat Well
EPPIC Treatment HORYZONS

Clinical remission Psychosocial recovery Maintenance of psychosocial gains

0 mo 6/9 months 24 months

Reduce DUP and Treat Well
Reduce DUP and Treat Well

16 core components of the EPPIC Model

─ Community Education and Awareness
─ Easy Access to Service
─ Home based care and Assessment
─ Access to streamed youth friendly inpatient care
─ Access to Youth Friendly sub-acute beds
─ Continuing Care Case management
─ Medical treatments
─ Psychological interventions
─ Functional recovery program
─ Mobile Outreach
─ Group Programs
─ Family Programs and Family Peer Support
─ Youth Participation and Peer Support
─ Partnerships
─ Workforce Development
─ Ultra-high risk Detection and Care
Reduce DUP and Treat Well

Roll out of EPPIC across Australia - Headspace

─ National Youth Mental

Health Foundation
─ Provides early intervention
for young people in
Australia aged 12 - 25
─ Free access to GPs,
Psychologists and
Psychiatrists
─ Youth friendly environment
Reduce DUP and Treat Well

Roll out of EPPIC across Australia – Headspace hYEPPS

─ Population
─ 23 million Australia
─ 316 million US
─ 35 million Canada
─ 9 headspace Youth Early
Psychosis Programs
─ Service in every state and
territory of Australia
─ Hub and spoke model
─ Fidelity to EPPIC Model
─ Capped case loads of 15 – 20
clients
Reduce DUP and Treat Well

DETECT – Early Intervention service for Psychosis in Ireland

─ Description of service
─ Campaign to reduce the DUP
─ Factors associated with the DUP
─ Unexpected consequences of reducing the DUP
─ National rollout of Early Intervention
Reduce DUP and Treat Well

DETECT – Early Intervention service for Psychosis in Ireland

– Study of all FEP cases between 1995 – 1999

– 171 cases
– Median DUP = 5 months
– Mean = 18 months
– Follow-up studies conducted at 4, 8 & 12 years
– Longer DUP associated with
– poor functional and symptomatic outcome (Clarke et al 2006)
– lower quality of life & functioning (Hill et al 2012)
– Lay the foundations for the establishments of early
intervention in Ireland
Reduce DUP and Treat Well

DETECT – Early Intervention service for Psychosis in Ireland

– Established in February 2006

– Covers 3 mental health service
catchment areas population of
390,000
– 75% urban & 25% rural
– Integrated model of service with
the local mental health service
– Referrals received from primary
care and Emergency Departments
Reduce DUP and Treat Well

–
Reduce DUP and Treat Well

Campaign to reduce the DUP – Professionals

GP Medical educational groups

Articles in GP Journals and Newspapers
Newsletters & Laminate sent to all GPs
Educational Sessions for ED Staff
Curriculum for Youth workers developed
Reduce DUP and Treat Well

Campaign to reduce the DUP – General Public

─ Storyline on Psychosis embedded in an Irish TV Soap Opera

─ 600,000 viewers from a population of 4 million
─ Survey of nearly 1000 people conducted 6 months later
─ Viewers had lower levels of stigma
─ Better knowledge on how to access care
─ More optimistic about outcome

Turner et al 2014 Early Intervention in Psychiatry

Reduce DUP and Treat Well

Campaign to reduce the DUP – General Public

– Play commissioned by DETECT to portray a young mans

experience of psychosis and recovery
– 45 minute play that is followed by a panel discussion about
psychosis
– Has toured across Ireland
Reduce DUP and Treat Well

DETECT – Identification of factors associated with DUP

─ 292 FEP cases over 5 year period

─ Median DUP of 4 months
─ No demographic factors (social class, migrant status)
associated with DUP
─ Most deprived neighbourhoods had a median DUP of
10.5 months compared to 3 months in the most
affluent neighbourhood (not statistically significant)
─ DUP not associated with the level of
─ social fragmentation
─ Population density
─ Social capital O’Donoghue et al 2015 In Press
Reduce DUP and Treat Well

Effects on the DUP

Period Median DUP

6

Median Months
5.5
5
Pre-DETECT 6 Months 4 4

2003 – 2005 1 3 3

2
DETECT 3 Months 1 1

2006 - 2010 0
1 2 3 4
Year
1Jackson et al European Psychiatry 2008
Reduce DUP and Treat Well

DETECT – Unexpected consequences of reducing the DUP

─ Rate of referral of ‘non-cases’

─ Examined the effect of having a low threshold to assess
potential cases of psychosis
─ Over 4 years – 632 referrals
─ 53% (N=338) FEP
─ 5% (N=34) UHR
─ 42% (N=260) ‘non-cases’
─ Rate increased from 1:1 to 3:1

O’Donoghue et al 2012 Early Intervention in Psychiatry

Reduce DUP and Treat Well

DETECT – Unexpected consequences of reducing the DUP

─ Diagnoses of
‘Non-cases’
─ 45% had a diagnosis
of mood or anxiety
disorder
─ Personality disorder
not assessed

O’Donoghue et al 2012 Early Intervention in Psychiatry

Reduce DUP and Treat Well

DETECT – Unexpected consequences of reducing the DUP

─ Does an EI service detect more cases with a very long DUP?

─ 323 FEP cases (172 EI service & 152 historical control)
─ EI service had 7.6% cases with a DUP of 2- 3 years compared
to 3.3% of historical control
─ EI service had 13.4% of cases with a DUP > 3 years vs 10.6%
─ Very long DUP associated with less insight, unemployment
and involuntary treatment
─ Review of literature shows approx. 10% have very long DUP
─ Little known about best treatment for this group
O’Donoghue et al 2014 Early Intervention in Psychiatry
Reduce DUP and Treat Well

National roll out of Early Intervention across Ireland

─ In 2011 the Health Service Executive (HSE) identified Early

Intervention for Psychosis as one of its priorities.
─ Recommended the establishment of 13 Early Interventions
services across the Republic of Ireland
─ Services would provide CBT, vocational support & caregiver
psychoeducation
─ Aim is to achieve a median DUP < 6 months initially and by
Year 2 - < 3months
Reduce DUP and Treat Well

Summary

─ Both help seeking delays and health service delays need to

be addressed to reduce the DUP
─ It is possible to reduce the DUP and sustain a low DUP – can
be done cheaply (but creatively)
─ A low threshold to refer suspected cases of psychosis needs
to be encouraged and barriers removed – however this leads
to a high number of ‘non-cases’
─ More research on what additional interventions might be
appropriate to identify the group with a very long DUP
earlier
Reduce DUP and Treat Well

Acknowledgments

Prof Patrick McGorry Prof Eadbhard O’Callaghan

Kerryn Purcell A/Prof Mary Clarke
Prof Eoin Killacky Kevin Madigan
A/Prof Mario Alvarez-Jimenez Niall Turner
Dr Sarah Bendall Dr Laoise Renwick
Dr John Lyne