NICE guidelines for psychosis and the Early Intervention Access & Waiting Times Targets

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1 NICE guidelines for psychosis and the Early Intervention Access & Waiting Times Targets Dr Frank Burbach South West IRIS EIP Preparedness Lead Early Intervention in Psychosis Service Development Workshop Monday 22 February 2016, Taunton Rugby Football Club Background on psychosis care The cost of poor treatment The benefits of evidence based EIP services Family interventions and CBTp 1

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3 Professor Sir Robin Murray THE ABANDONED ILLNESS Schizophrenia Commission Report (2012) Imagine suddenly developing an illness in which you are bombarded with voices from forces you cannot see, and stripped of your ability to understand what is real and what is not. You discover that you cannot trust your senses, your mind plays tricks on you, and your family or friends seem part of a conspiracy to harm you. Unless properly treated, these psychotic experiences may destroy your hopes and ambitions, make other people recoil from you, and ultimately cut your life short. Some 220,000 people in England have such psychotic experiences we probably all know a family who is affected, but the stigma is such that they may be keeping it a secret. it is unacceptable that: People with severe mental illness such as schizophrenia still die years earlier than other citizens. ƒschizophrenia and psychosis cost society 11.8 billion a year but this could be less if we invested in prevention and effective care. ƒincreasing numbers of people are having compulsory treatment, in part because of the state of many acute care wards. Levels of coercion have increased year on year and are up by 5% in the last year. ƒtoo much is spent on secure care billion (19% of the 2011 mh budget)- with many people staying too long in expensive units when they are well enough to start back on the route to the community. ƒonly 8% of people with schizophrenia are in employment, yet many more could and would like to work. Only 1 in 10 of those who could benefit get access to true CBT despite it being recommended by NICE ƒ. Families who are carers save the public purse 1.24 billion per year but are not receiving support, and are not treated as partners. 3

4 Schizophrenia Commission Report (2012) The fragmentation of services means that people who have a recurrence of their psychosis lose the established relationships with professionals they trust, and instead feel shuttled from one team to another as if on a factory production line. Schizophrenia Commission Report (2012) Sadly, the great innovation of the last 10 years which everyone says works well the Early Intervention in Psychosis services are currently being cut. Instead, the obvious question is: why is it that the integrated therapies that work so well in early intervention are not being offered to people throughout the course of their illness? 4

5 Lost Generation: Protecting Early Intervention in Psychosis services RETHINK % of EIP services say their budget has decreased in the past year, some by as much as 20% 58% of EIP services have lost staff over the last 12 months 53% say the quality of their service has decreased in the past year Many young people face unacceptable delays in accessing EIP services, greatly reducing their chances of recovery The cavalry arriving in the nick of time? Paul French 5

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7 Why a Standard? 14 7

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9 CBTp & FI Effectiveness of FI NICE GUIDELINES 2014 Update Robust and consistent evidence for the efficacy of family intervention 32 RCTs (N=2,429) When compared with standard care there was a reduction in the risk of relapse (NNT=4 at end of treatment ; = 6 up to 12 months post treatment) Reduced hospital admission during treatment & reduced severity of symptoms during & up to 24 months following FI. May also be effective in improving additional critical outcomes, e.g. social functioning & patient s knowledge of the disorder. 9

10 Effectiveness of CBTp NICE GUIDELINES 2014 Update Effective in reducing rehospitalisation rates up to 18 months following the end of treatment & robust evidence indicating that the duration of hospitalisation was also reduced (8.26 days on average). Effective in reducing symptom severity (PANSS & BPRS total scores) at end of treatment and up to 12 months f-u Robust small to medium effects for reductions in depression Some evidence for improvements in social functioning up to 12 months. Cost Effectiveness CBT is likely to be an overall cost-saving intervention for people with schizophrenia because the intervention costs are offset by savings resulting from a reduction in the number of future hospitalisations associated with this therapy. P238 Family Intervention is associated with net cost savings when offered to people with schizophrenia in addition to standard care, owing to a reduction in relapse rates and subsequent hospitalisation. p274 Net cost savings from FI are probably higher than those estimated in the guideline economic analysis (which used relapse data that referred to the period during treatment with FI. However, there is evidence that FI also reduces relapse rates for a period after completion of the intervention.) 10

11 NICE Guidelines for Psychosis & Schizophrenia (2009) FAMILY INTERVENTIONS Offer family intervention to all families of people with psychosis or who live with or are in close contact with the service user. This can be started either during the acute phase or later, including in inpatient settings. Family intervention should: include the person with psychosis or schizophrenia if practical be carried out for between 3-12 months; at least 10 planned sessions have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work. NICE Guidelines for Psychosis & Schizophrenia (2009) COGNITIVE BEHAVIOUR THERAPY - - Offer CBT to all people with psychosis. - - This can be started either during the acute phase or later, incl. in inpatient settings - - CBT should be delivered one-to-one over at least 16 planned sessions -- Follow a treatment manual & include at least one of the following components: people monitoring their own thoughts, feelings or behaviours with respect to their symptoms or recurrence of symptoms promoting alternative ways of coping with the target symptom reducing distress improving functioning. 11

12 HEE funded Family Interventions and CBTp training 23 HEE funded CBTp training 1. Skills workshops for experienced CBTp practitioner therapists 2. Supervisor training 3. Modular top-up CBTp training 4. A two-year PGDip in CBTp training Backfill will only be paid for staff on the 2-year PGDip pathway. Book places & notify Henrietta Mbeah-Bankas 24 12

13 HEE funded FI training 3 March Introduction (Exeter) 1. Exeter: 7 March 22 March 2. Bodmin: 21 June - Weds 13 July 3. Bristol: 19 September - Tues 11 October 4. Exeter: 28 November - 21 December 25 FAMILY INTERVENTIONS for Psychosis & other Serious Mental Health Problems HEE funded Foundation level AFT accreditation applied for Course lead: Frank Burbach Introduction to CBT for Bipolar Disorder

14 The 10 day course 1. Intro to systemic practice 1: rationale, history, confidentiality, Services 2. Intro to systemic practice 2: basic concepts (e.g. circular causality, contexts, Family Beliefs, Family Life Cycle) 3. Intro to systemic practice 3: basic skills (e.g. engagement, interviewing, co-working) 4. Therapeutic self and reflexive practice (incl. genograms) 5. Culture and diversity, power and difference (incl. Levels of context, Gender, Race) 6. Psychosis 1: development of FI & Open Dialogue, 6 Phases, assessment 7. Psychosis 2: Collaborative Formulation & Therapeutic Interviewing, children 8. Psychosis 3: Communication Training & Problem Solving 9. Bipolar Disorder (incl. Psychoeducation, Activity Scheduling, Behavioural Activation) 10. Psychosis 4: Relapse Prevention, ending, supervision & sustainable services 27 Integrated Family Intervention model Six overlapping phases: The provision of information and emotional and practical support Identification of patient, family and wider network resources Encouraging mutual understanding Identification and alteration of unhelpful patterns of interaction Improving stress management, communication and problem solving skills Relapse prevention planning. 14

15 ENVIRONMENTAL STRESS 09/03/2016 Please do not hesitate to contact us if you have any queries. More Information Available on Request #ei2015 STRESS-VULNERABILITY MODEL SYMPTOMATIC WELL Threshold Low Biological Vulnerability High Burbach

16 COGNITIVE INTERACTIONAL ANALYSIS inactive withdraws psychotic symptoms 's/he is lazy' he/she is unreasonable and doesn t understand criticizes questions requests shouts u Burbach 2016 rbach 2012 COGNITIVE OR BEHAVIOURAL INTERVENTIONS Person with psychosis Behavioural Interventions GOAL SETTING POSITIVE REINFORCEMENT Empathic reappraisals He/she is concerned/ cares about me and is trying to help Partner Empathic reappraisals He/she is ill / struggling with a serious mental health problem Behavioural Interventions Communication Training (BFT) It really makes me feel cross when you Please do u Burbach 2016 rbach

17 VIRTUOUS COGNITIVE INTERACTIONAL CYCLE Talk about experiences (Symptoms may decrease) He/she cares about me and are trying to help Going through a difficult time; convalescence Sympathy; talk; be available; help Burbach 2016 Burbach 2012 Partner Assisted Disorder Specific Couple / Family Therapy PA: Psychoeducation; stress-vulnerability; medication concordance; goal setting; coping strategy enhancement; EWS & relapse prevention planning DS: Addressing stress related to caring, grief, loss; Reducing criticism/ blame/ hostility/ conflict; reducing over-involvement; increasing understanding/ developing acceptance, tolerance & compassion Communication & problem solving skills Cognitive interactional cycles CFT: Primary distress & Secondary distress Modifying behavioural interactions (micro level) Global negative emotions (sentiment override) Emotional injury (attachment or identity injury) Family beliefs/ narratives/ attachment (FoO) (macro level) Environmental stress 17

18 Case examples: Woman (50 s) doesn t accept diagnosis of bipolar disorder - psychoeducation (S-V model) (PA) - focus on loss of roles related to husband s retirement and youngest son leaving home; resentment of her husband s bossy behaviour (CT) Man with psychosis, woman with depression - initial focus - managing his psychotic symptoms (PA) - increasing care and mutual understanding (DS) - improving communication (CT) Subsequent focus on setting boundaries re. visits by wider family (CT/FT) B Burbach