Innovations in Community-Based Mental Health Care PDF

**Innovations in Community-Based Mental Health Care: an overview of meta-analysis** **Key Findings:** 1. **Intervention Effectiveness:** - **Case Management (CM), Early Intervention Services (EIS), and Caregiver-Directed Interventions:** - Superior to standard care in re...

**Innovations in Community-Based Mental Health Care: an overview of meta-analysis** **Key Findings:** 1. **Intervention Effectiveness:** - **Case Management (CM), Early Intervention Services (EIS), and Caregiver-Directed Interventions:** - Superior to standard care in reducing hospital admissions. 2. **Psychosocial Outcomes:** - **EIS:** - High-quality evidence of a small positive effect on global functioning. - **Intensive Case Management:** - Moderate-quality evidence of a similar small effect on global functioning. - **Family Interventions:** - Large effect on global functioning supported by moderate-quality evidence. 3. **Quality of Life:** - **EIS and Self-Management Education:** - Both showed a small positive effect on quality of life, with moderate-quality evidence. 4. **Research Gaps:** - Significant research exists on effective Community Mental Health (CMH) models. - Notable gaps in innovative CMH strategies that have not been covered in meta-analyses. **Summary** Overall, EIS, Intensive Case Management, and family interventions demonstrate effectiveness in reducing hospital admissions and improving psychosocial outcomes. While there is substantial research, further exploration of innovative CMH models is needed. *Esposti et al. 2022 - **Trends in psychiatric admission in UK by diagnosis 1998-2020*** *Notes:* - Rates of recovery are higher in North America and higher in pre-'97 studies - Doesn't support and improvement in the prognosis of psychosis - Hasn't really shifted in the past 20/30 years *Notes:* - Over 20 years - Schizophrenia shows as a slow decline in hospital admissions, not as substantial as in other conditions - Decline is biggest for depression and dementia **What predicts recovery from first episode of psychosis?** *Lally et al. 2018 - **Meta-analysis showing lower rate of recovery (but higher initial remission) in more recent studies*** **Trends in Early Psychosis Outcomes** - Despite 30 years of EIP initiatives, it's not yet evidenced that prognosis overall has improved -- remission from first episode has increased, but rates of full recovery possibly declined - In the UK: schizophrenia admissions have gone down, but less so than other diagnoses: MHA (mental health act) detentions have gone up - Prognosis reported to be better in Lower and Middle Income Countries, where services less evolved, and also in USA - *Can you think of any reasons? -* Fewer Urban Areas & more collectivists societies / ?different attitudes towards episodes of Psychosis / though this is going away, possibly due to more urbanisation --- *though unsure of reason* Early Intervention in Psychosis initiatives clearly have a significant effect on outcomes in trials but they have not so far made a detectable substantial difference to long-term psychosis outcomes across the population: *What changes might make a difference to these outcomes?* - To provide support for a longer duration - Shorter waiting-time for treatment **Barriers to progress in improving psychosis outcomes (1): difficulties detecting ARMS and false positives** - Occurrence of false positives - Difficulties finding individuals in ARMS - Most individuals present to services when they develop psychosis (don't come through the ARMS service) ***The potential of early detection:*** 50.2% (half) of people with psychosis/bipolar have history of Child and Adolescent Mental Health Service (CAMHS) contact. - 6 years median from CAMHS contact to psychosis/bipolar diagnosis ***Challenges in finding people with ARMS:*** Proportion of people entering an early psychosis caseload who have been detected in ARMS services beforehand in two service systems. ***Limited predictive validity of ARMS detection*** *Fusar-Poli et al. 2012* Meta-analysis of transition rates to psychosis for people assessed as having an At Risk Mental State - 32% at 3 years - The harder you look for people in the general population, the more false positive you will find *Lang et al. 2021* Systematic review of transition rates to psychosis for under 18s assessed as having risk mental state: **15% pooled estimate after 5 years** **Approaches to improving detection of At Risk Mental State** *Extensive research in how to better predict/identify ARMS with more markers, incl. evidence on clinical, genetic, cognitive, EEG and MRI markers of risk for psychosis.* Development of risk calculators: - Combining clinical screening tools with **biomarkers e.g.** based on reports of imaging and EEG abnormalities prior to psychosis onset and of genetic markers of increased risk - From including cognitive markers (e.g. working memory, executive functioning) - From routinely recorded data on mental health records and interactions/engagement with services - Machine learning/AI approaches: combine risk markers to achieve 70-80% prediction for ARMS in research settings Application limited by lack of evidence on how to find people with ARMS -- more assertive screening efforts increase false positive rates. Though hasn't been rolled out in clinical practice yet. **Approaches to improving management of At Risk Mental States** Development and implementation of more effective interventions with less risk of unintended negative effects or complications/harm: - Despite some disappointing results, CBT still most promising in meta-analyses (e.g. *Mei et al 2021*: reduction in incidence at 12-months (RR = 0.52, 95%CI = 0.33--0.82) Scope for improvement in CBT approaches e.g. through improving approaches to trauma & other comorbidities, combining with social package Development of transdiagnostic approaches applicable to multiple conditions: monitoring, transdiagnostic interventions for symptoms and social difficulties - Using CBT to target other co-morbidities such as depression, trauma etc. may help to provide support to all without the stigma attached to psychosis - May help full blown psychosis from being developed in the first place **Barriers to progress in improving psychosis outcomes (2): limited reach of Early Detection Initiatives** - Approaches to reducing DUP in people who already have psychosis only seem to succeed when education provided widely to general public, including families - Interventions targeting GPs/other providers don't appear to influence pathways for sufficient people to achieve an effect - Remarkably little literature or service development compared with ARMS - *Only minimal studies on Early Intervention in Psychosis* - Only interventions that appear to have success, are those that focus on the wider general public, incl. families - most likely to bring individuals to services at an earlier point than they are currently **Reducing DUP: Directions for Research and Intervention Development** - MINDMap at Yale: First large study of the social media age on a DUP reduction initiative: reduction shown in DUP following a public information campaign vs. geographical control - School-based initiatives: yet to be tested - Youth mental health approaches e.g. ORYGEN in Melbourne, YOUTHSPACE in Birmingham. Advantages: - More efficient to look for **all** significant mental heath problems - it needs to be more broad - People with ARMS who don't develop psychosis often do develop other conditions - Fewer issues of psychosis when not targeting psychosis Robust evidence not yet available on psychosis detection. - Better to focus on a wider population - e.g. young people struggling with a range of severe mental health problems - More push for detection in Early Interventions - e.g. Depression - But are more likely to implement engagement with a service **Barriers to progress in improving psychosis outcomes (3): Limitations of intervention delivery within EIS** - Service rather than intervention-level model: no substantial evidence on critical ingredients - Lack of evidence on individualising to culture, stage of illness, comorbidities - Generic model '1 size fits all' - Limited focus on/lack of effective interventions for trauma, important comorbidities such as depression, "personality disorder", cannabis use, trauma - Not much co-production of services - Not much service user or carer input in the running or structure of the service - Severe social difficulties among many service users: lack of societal or individual strategies to address them - Lack of funding of services and severe social problems for the more deprived areas of society **Ethnic differences in receipt of CBTP (CBT for Psychosis) in Early Intervention Services (*Schlief et al. Mental Health Policy Research Unit, 2023)*** *Notes:* - People from certain ethnic groups, incl. Bangladeshi & Pakistani - less likely to be getting CBT for Psychosis if using EIS - Ensure to effectively individualise care and reaching everyone **Potential routes to improving EIS quality and outcomes** - Systematic approach to understanding critical ingredients for good outcome, ensuring evidence-based components are implemented - Focus on overcoming barriers to engagement, including at societal level (stigma, racism etc.) - Individualised care -- focus on collaborative care planning, choice, adapting to culture, disability, other individual needs: co-produced interventions - Thorough implementation of self-management/crisis planning interventions - Teach individuals to be aware of their own early warning signs and management plan - Effective strategies for physical health from the start - Development and testing of interventions for comorbidities - Specialist approaches to bipolar - Evaluation of peer support and strategies for meeting social needs **Barriers to progress in improving psychosis outcomes (4): loss of effect after leaving EIS** - Mixed results regarding maintenance of difference between EIS and control following EIS discharge - Robinson et al. (2022) in US Raise Trial: following up trajectory after discharge suggests modest continuing benefit from EIS - High relapse rate found in year after discharge from EIS (Puntis et al) - Some evidence also for benefits from extended EIS e.g. up to 5 years for selected patients - Mixed results may reflect large variations in control groups **Research and intervention development - directions to achieve sustained effect** - Better evidence needed on: - Whether EIS benefits are sustained beyond discharge to primary care - Whether extending EIS has benefits, and if so, for whom - Discharge warrants further investigation: who should go to which service, and what makes for successful discharge? - EIS as high quality psychosis care that should be available for all: many challenges in maintaining quality across system, many societal challenges for service users ***Renwick et al. 2022 -* Stakeholder-identified research priorities for early intervention in psychosis** **Summary** - Much hope invested in early intervention in psychosis as means of improving outcomes (and model for other conditions) - Consensus that it is effective and cost-effective in achieving modest improvement in prognosis while people are with the service - Critical ingredients of effective EIS, best longer-term approaches to improve prognosis are still uncertain - At risk mental states: much research knowledge regarding markers, better approaches still needed to putting this into practice, avoiding iatrogenic harm - Early detection of psychosis and shortening DUP: strangely neglected field with scope for fresh attention to effective approaches (including youth mental health services)