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09/03/2016
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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
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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 15-20 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 - £1.2 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.
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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?
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Lost Generation: Protecting Early
Intervention in Psychosis services
RETHINK 2014
• 50% 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
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Why a Standard?
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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.
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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.)
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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
NICE Guidelines for Psychosis & Schizophrenia (2009)
-- 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.
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HEE funded
Family Interventions and
CBTp training
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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
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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
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Introduction to CBT for Bipolar Disorder
FAMILY INTERVENTIONS for Psychosis & other Serious
Mental Health Problems HEE funded Foundation level AFT accreditation applied for
Course lead: Frank Burbach
© 2016
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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
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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.
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More Information Available on Request
http://time4recovery.com
@Time4Recovery #ei2015
Please do not hesitate to contact us if you have any
queries.
STRESS-VULNERABILITY MODEL
EN
VIR
ON
ME
NTA
L S
TR
ES
S
Low Biological Vulnerability High
SYMPTOMATIC
WELL Threshold
© Burbach 2012
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COGNITIVE INTERACTIONAL ANALYSIS
criticizes
questions
requests
inactive
withdraws
psychotic symptoms
shouts
's/he is lazy'
‘he/she is unreasonable
and doesn’t understand’
© Bu © Burbach 2016 rbach 2012
COGNITIVE OR BEHAVIOURAL INTERVENTIONS
GOAL SETTING
POSITIVE REINFORCEMENT
Communication Training (BFT)
“It really makes me feel cross
when you … Please do …”
“He/she is
concerned/ cares
about me and is
trying to help”
”He/she is ill”/
“struggling with a serious
mental health problem”
Person with psychosis Partner
Behavioural Interventions
Behavioural Interventions
Empathic reappraisals
Empathic reappraisals
© Bu © Burbach 2016 rbach 2012
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“Going through a
difficult time;
convalescence”
“He/she cares
about me and
are trying to
help” Sympathy; talk; be available;
help
Talk about experiences
(Symptoms may decrease)
VIRTUOUS COGNITIVE INTERACTIONAL CYCLE
© © 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
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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 2016 2012
