Psychosocial Interventions for Psychosis and Bipolar PDF

**Prep Notes:** **Prep: Schizophrenia Commission Report** **Overview: The Schizophrenia Commission Report examines the state of care and services for individuals with schizophrenia, highlighting systemic issues and providing recommendations for improvement.** **Key Findings:** 1. **Service Gaps...

**Prep Notes:** **Prep: Schizophrenia Commission Report** **Overview: The Schizophrenia Commission Report examines the state of care and services for individuals with schizophrenia, highlighting systemic issues and providing recommendations for improvement.** **Key Findings:** 1. **Service Gaps:** - **Significant inconsistencies in the quality of care across different regions.** - **Lack of integrated services that address both mental health and physical health needs.** 2. **Diagnosis and Treatment:** - **Delays in diagnosis and inadequate treatment options.** - **Need for more tailored approaches that consider individual patient needs.** 3. **Stigma and Discrimination:** - **Persistent stigma associated with schizophrenia affects treatment access and quality of life.** - **Recommendations for public awareness campaigns to combat stigma.** 4. **Support for Families and Caregivers:** - **Insufficient support for families, who play a crucial role in the care of individuals with schizophrenia.** - **Emphasis on providing resources and education to families.** 5. **Research and Innovation:** - **Calls for increased funding and focus on research to develop new treatments and improve existing ones.** - **Highlighting the importance of involving service users in research.** **Recommendations:** 1. **Service Improvement:** - **Implementing integrated care models that provide holistic support.** - **Ensuring equitable access to quality services regardless of geographic location.** 2. **Early Intervention:** - **Promoting early diagnosis and intervention to improve long-term outcomes.** 3. **Education and Training:** - **Training for healthcare professionals on the complexities of schizophrenia.** - **Enhancing knowledge of care approaches among general practitioners.** 4. **Policy Changes:** - **Advocating for changes in mental health policy to prioritize schizophrenia care.** 5. **Involvement of Service Users:** - **Encouraging the active involvement of people with schizophrenia in decision-making processes regarding their care.** **Conclusion** **The Schizophrenia Commission Report underscores the urgent need for reform in the care of individuals with schizophrenia, advocating for improved services, reduced stigma, and enhanced research efforts to foster better health outcomes.** **Summary:** **From our evidence, we concluded that despite the clear progress made in some areas, it is unacceptable that:** - **People with severe mental illness such as schizophrenia still die 15-20 years earlier than other citizens.** - **Schizophrenia and psychosis cost society £11.8 billion a year** - **Could be less if we invested in prevention and effective care.** - **Increasing 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.** - **Too much is spent on secure care - £1.2 billion or 19% of the mental health budget last year - with many people staying too long in expensive units when they are well enough to start back on the route to the community.** - **Only 1 in 10 of those who could benefit get access to true CBT despite it being recommended by NICE.** - **Only 8% of people with schizophrenia are in employment, yet many more could and would like to work.** - **Only 14% of people receiving social care services for a primary mental health need are receiving self-directed support (money to commission their own support to meet identified needs) compared with 43% for all people receiving social care services.** - **Families who are carers save the public purse £1.24 billion per year but are not receiving support, and are not treated as partners.** - **Service users and family members dare not speak about the condition.** - **87% of service users report experiences of stigma and discrimination.** - **Services for people from African-Caribbean and African backgrounds do not meet their needs well. In 2010 men from these communities spent twice as long in hospital as the average.** **Prep: Bipolar Commission Report** **Key findings include:** - **More than a million people live with bipolar in the UK** - **More than five million friends and family are significantly affected by a loved one's bipolar** - **After first telling a healthcare professional about symptoms, it takes an average of 9.5 years to get a diagnosis of bipolar** - **Bipolar costs the UK economy £20 billion a year -- 17% of the burden of disease for mental illness** - **Someone with bipolar takes their own life every day** - **10% of our community said they had attempted to take their own life in the last six months** - **More than half of people with bipolar have been hospitalised due to their bipolar** - **44% of people with bipolar are obese** - **People with bipolar die 10-15 years earlier than the general population** - **44% of people have experienced stigma in the workplace** **July 2024** **Bipolar UK presented a report based on the findings of a survey of 1000+ people in the workplace. Key findings include:** - **the employment rate among people with bipolar is significantly lower than the average employment rate in the general population** - **24% of respondents hadn't told anyone in the workplace about their diagnosis of bipolar** - **three in 10 respondents who had told people in the workplace about their diagnosis of bipolar later regretted it** - **44% of respondents reported experiencing stigma because of their bipolar** - **57% of respondents reported a lack of understanding as a barrier to thriving in the workplace** **Study Notes: Bipolar Commission Report** **Overview: The Bipolar Commission Report assesses the current state of care for individuals with bipolar disorder, identifying gaps in services and providing recommendations for improvement.** **Key Findings:** 1. **Diagnosis and Awareness:** - **Delays in diagnosis are common, leading to inadequate treatment.** - **Increased public and professional awareness of bipolar disorder is needed to reduce stigma.** 2. **Service Availability:** - **Significant variability in the quality and availability of services across regions.** - **Lack of access to specialized care and support services.** 3. **Treatment Gaps:** - **Many patients do not receive evidence-based treatments.** - **Insufficient integration of physical and mental health services.** 4. **Impact on Quality of Life:** - **Bipolar disorder significantly affects daily functioning, relationships, and overall quality of life.** - **Family members often experience stress and need additional support.** 5. **Research and Innovation:** - **Need for more research into effective treatments and management strategies.** - **Emphasis on involving service users in research initiatives.** **Recommendations:** 1. **Improved Diagnosis:** - **Enhance training for healthcare professionals to recognize and diagnose bipolar disorder more effectively.** - **Implement standardized assessment tools for early diagnosis.** 2. **Integrated Care Models:** - **Promote integrated care approaches that address both mental and physical health needs.** - **Ensure continuity of care throughout the patient's treatment journey.** 3. **Support for Families:** - **Provide resources and support for families to help them manage the challenges associated with bipolar disorder.** - **Encourage family involvement in treatment planning.** 4. **Public Awareness Campaigns:** - **Launch campaigns to educate the public about bipolar disorder to reduce stigma and promote understanding.** 5. **Funding for Research:** - **Advocate for increased funding for research focused on bipolar disorder treatment and management.** **Conclusion** **The Bipolar Commission Report highlights the urgent need for improvements in diagnosis, treatment, and support services for individuals with bipolar disorder, emphasizing the importance of integrated care and public awareness to enhance patient outcomes.** **Prep: Investing in Recovery** ***A report commissioned by the charity Rethink, led by a team of LSE health economists, including some of the leading UK mental health economics. It makes a case for investing much more in recovery-focused psychosocial interventions. Economic modelling is one of the forms of evidence that policy makers tend to be most interested in.*** **Introduction** **Background:** - **In December 2013, Rethink Mental Illness commissioned a study to build on previous work (e.g., Schizophrenia Commission).** - **Aim: Prepare economic analyses of interventions and care pathways for individuals with schizophrenia and psychosis.** **Approach:** - **Conducted by teams from:** - **Personal Social Services Research Unit (PSSRU) at LSE** - **Centre for Mental Health** - **Centre for the Economics of Mental and Physical Health (CEMPH) at King's College London.** - **Funded by the Department of Health and PSSRU reserves.** **Report Structure:** 1. **National Context: Business case for recovery-focused interventions.** 2. **Economic Evidence: Overview of various interventions, including:** - **Context and nature of each intervention.** - **Evidence of effectiveness and cost-effectiveness.** - **Policy and practice implications.** **Intervention Selection:** - **Focus on a wide range of interventions that promote early detection, symptom management, and long-term recovery (e.g., education, employment, housing).** - **Exclusions:** - **Medication alone (covered in NICE guidelines).** - **Drug and alcohol treatment interventions (lack of specific cost-effectiveness evidence).** **Methodology:** - **Costs and benefits measured at 2012/13 prices.** - **Adjustments made using health service pay and prices index.** - **International cost data converted using OECD purchasing power parity.** - **Future economic impacts discounted at 3.5% per year.** **Key Findings:** - **Analysis of 15 interventions, providing quantitative and narrative details.** - **Emphasis on identifying effective interventions that offer good value for money and potential cost savings for the NHS.** **Conclusion** **The study aims to establish a clear business case for improving local leadership and commissioning services for schizophrenia and psychosis, focusing on effective, evidence-based interventions.** **Summary** **Financial Overview:** - **In 2012/13, the health service spent £2.0 billion on psychosis services.** - **Inpatient Care: Accounts for 54% of total spending, averaging £350 per day.** - **Community Care: Average cost is £13 per day, indicating a skew towards expensive inpatient services.** **Business Case:** - **Strong justification for investing in early intervention and community-based services that reduce inpatient admissions and provide value for money.** **Key Interventions Analyzed:** - **Early Detection (ED) services** - **Early Intervention (EI) teams** - **Individual Placement and Support (IPS)** - **Family therapy** - **Criminal justice liaison and diversion** - **Physical health promotion** - **Crisis Resolution and Home Treatment (CRHT) teams** - **Supported housing** - **Crisis houses** - **Peer support** - **Self-management** - **Cognitive Behavioural Therapy (CBT)** - **Anti-stigma campaigns** - **Personal Budgets (PBs)** - **Welfare advice** **Cost-Effectiveness Findings:** - **Many interventions shown to prevent relapse and reduce the need for expensive care, contributing to better recovery outcomes (e.g., employment, housing).** - **Notable evidence for:** - **EI Teams: Net savings of £7,972 per person after four years; £15 saved for every £1 invested over ten years.** - **Smoking Cessation: £1,255 cost to gain an additional Quality-Adjusted Life Year (QALY).** - **Peer Support: £4.76 gained for every £1 invested.** - **CBT: Cost per QALY of £27,373, below NICE\'s £30,000 threshold.** **Recommendations:** - **Local and regional commissioning should leverage this evidence to inform clinical pathways and interventions.** - **Focus on implementing clinically effective interventions that also provide financial savings for reinvestment in care.** **Conclusion** **The report emphasises the economic viability of investing in effective, recovery-focused interventions for psychosis, advocating for a shift towards community-based care to improve outcomes and reduce costs.** **Prep: Physical Health of People with Severe Mental Illness (SMI)** **Scientific Rationale for Primrose Programme** **Increased risk of cardiovascular disease (CVD) and mortality in people with schizophrenia, psychosis or bipolar.** - **Die up to 20 years earlier than the general population** - **Those under 50 with these conditions are more than 3 time at risk of CVD than their contemporaries** - **The mortality gap is increasing** **Why?** - **Risk factors incl. lifestyle, smoking, obesity, diabetes, high cholesterol, stress, poverty** - **Illness factors and antipsychotic medications** - **Diagnostic overshadowing and sub-optimal management of CVD** **CVD mortality in people with schizophrenia in UK general practices 1987-2002** **Overview of Primrose Research Programme** **National Institute for Health Research (NIHR) Programme Grant with 3 main work packages:** 1. **Develop a new tool to better predict CVD risk in people with severe mental illnesses (SMI)** 2. **Compile the best available evidence and develop a service and training package for GP practice nurses and HCA's to help lower CVD risk in people with SMI** 3. **Test the clinical and cost effectiveness of this service and training package (Primrose) in a 12-month trial delivered in GP Practices.** **Aim: To test the effectiveness and cost effectiveness of a practice nurse/HCA led service to reduce cholesterol and CVD risk in people with SMI.** **Method: 12-month cluster RCT co-ordinated in 6 recruitment waves. 76 general practices.** **Participants: People with SMI. Raised cholesterol and one other CVD risk factor** **Intervention: Primrose service + British Heart Foundation leaflets vs Treatment as Usual + BHF leaflets** **Primary outcome: Total cholesterol at 12 month fl/u.** **Secondary outcome: BMI, HBA1c, waist circumference, blood pressure, CVD risk scores, diet, physical activity, smoking, alcohol use, medication adherence, statin prescriptions, wellbeing, service use and costs.** **Economic Analysis: Health care perspectives** **Data Collection: Baseline, 6 and 12 month by research nurses in clinical research networks.** **What is the Primrose Service?** - **Two days training and a manual for practice nurses/HCA** - **8-12 appointments over 6 months** - **Number of appts depends on patient goals and treatment pathways (more intensive at the start if providing behavioural support.** - **Regular appts over 6 mnths** - **Final follow-up appt in month 9** - **Support patients to change behaviour** - **E.g. taking medication, stopping smoking, improving diet, increasing physical activity or reducing drinking** - **Refer on to existing support services** **and/or** - **Brief behavioural support provided directly** - **Follow-up and monitoring incl. attendance at services and progress with health goals** **Behaviour Change Strategies** 1. **Goal setting** 2. **Action planning** 3. **Forming habits** 4. **Recording behaviour** 5. **Reviewing goals** 1. **Use COM-B model to help patient identifying factors influencing their behaviour** 2. **Generate solutions on whether increasing capability, opportunity and or motivation will help** 3. **Translate the solution into a SMART goal and action plan** 4. **If a solution can't be identified, set an easier goal or a new goal** 6. **Giving positive feedback** 7. **Involving supportive others** 8. **Coping with setbacks** **Headline results:** - **327 pts and 76 GP practices recruited for study across UK** - **289/327 pts followed up at 12 months (88%)** - **155 pts randomised to receive the intervention and 172 pts randomised to receive routine care** - **Total cholesterol decreased in both Primrose intervention and treatment as usual** - **No significant difference in cholesterol between groups** - **No significant differences in secondary CV outcomes** - **Overall cost were lower in Primrose** - **Mean difference = -£895** - **Lower psychiatric admission cost in Primrose = -£799** **Take home messages from Primrose** - **Cholesterol decreased in both groups at 12months** - **Reduced admissions and cost with Primrose intervention - ?Continuity effect** - **Intervention deliverable** - **Excellent attendance at intervention - mean of 6 sessions** - **Good delivery of 'goal setting' but little attention to statins which do work in SMI** - ***Positive feedback from nurses and HCAs*** **UK trails in smoking and weight reduction for SMI** **Summary:** - **High levels of smoking, obesity, diabetes and high cholesterol in SMI** - **Mortality gap and high level of cardiovascular and respiratory problems** - **Careful monitoring and intervention needed** - **Interventions have been developed and delivered for smoking, obesity and combined risk factors (Primrose)** - **Results seem to indicate that more sustained, longer term interventions needed, incl. relevant medications.** **Psychosocial Interventions for Psychosis and Bipolar:** *Prof Sonia Johnson* **Notes:** **Psychosocial Interventions in Psychosis and Bipolar Disorder** **What does research tell us about:** - The difficulties people with psychosis/bipolar face in their lives and the evidence on the course of their illnesses. - Potential approaches to improving the prognosis of psychosis and bipolar disorder and to promoting recovery? - Potential approaches to improving improve social participation and quality of life among people with psychosis and bipolar disorder **The course of psychosis/schizophrenia** - *Lally et al (2017)*: Systematic review and meta-analysis of studies of psychosis outcome after first onset -- 19,000 people in total in above studies - **Remission** (getting better (back to normal) following first episode): pooled rate 58% - Poor remission in studies before 1976, but little change since then. - **Recovery**: Sustained period of at least 2 years good functioning and few or no symptoms: pooled estimate 38% had recovered after mean follow-up 7 years. - High rates of recovery in USA, lower in Europe - Hadn't changed over time - possibly worse - Better outcome reported from lower and middle income countries, but uncertainty about methods (continuing debate) - Huxley et al. (2021): 21st century studies: - Prognosis better for first episode psychosis than 20th century - Annual remission rate after multiple episodes declining, especially after 2008 financial crash (long-term outcome had become worse) - Lower and Middle Income Countries - outcomes similar or better, especially employment (tend to have higher employment rates, possibly easier to get jobs and less specialist jobs) - Employment rates have declined in higher income countries for those with mental illness - though previously may have been paid a low wage and doing 'basic' jobs **The course of Bipolar Disorder** Research is not strong not as much bipolar research available compared to psychosis (diagnostic problems hamper), but: - Most have relapsing/remitting course - continue to have episodes across lifetime though make a good recovery in-between - A Stage model of bipolar recently discussed - Approx. 15% **chronically unwell** on long-term follow-up (e.g. 15 yrs -- *Coryell et al., 1999*) - **16% in remission (been well) for 5 years** on 40 year follow up (*Angst and Preiseg, 1994*): - **Median time being ill**: 20% - 44% (*Carlson et al. 2012; Keck et al., 2003*). - Majority of time depressed when not functioning well the rest of the time. - Little evidence of change in prognosis in past few decades **A Challenge** - Not much evidence of progress in achieving substantial change in mental health outcomes for people with severe mental health problems such as psychosis and bipolar - Introduction of **antipsychotics(Lithium)/deinstitutionalisation** may have been **last significant shift** (1950s) - Many common physical long-term conditions (Cancer, CVD) have seen steady progress - Outcomes may still be better, or at least as good, in countries with little mental health care (*but disputed* ) - We really still need to start moving the needle on psychosis/bipolar outcomes, for clinical populations not just trial participants **Why have we not done better?** - Neuroscience/Pharmacology: Still investing and waiting for the great leap forward - Understand the basis a lot better from these perspectives than previously - Psychology: Small benefits so far from interventions that have been hard to implement widely - Difficult to find larger effects in Psychosis and Bipolar seems more difficult - Innovative service models: Benefits from EI, but short term. Changing service organisation may not sufficiently change content of care. - Large scale implemented model may have the best evidence at the moment - The implementation gap: translation of positive findings to practice often slow/doesn't occur - Observation is across healthcare/MHC - there's many years before wide role out of interventions found to be effective in trials - Still research into the barriers of implementation - E.g. Family Intervention in Psychosis - lots of studies supporting large impacts at an early stage in psychosis to reduce high expressed emotion - though not greatly implemented - Social determinants of mental health: hard to mitigate impacts of austerity, inequality etc. - Inequality has risen in the world in the last few decades - A lot of traumatic events have happened in the world - Problems of injustice/lack of compassion in services - A lack of quality in care - Stigma/lack of equity with physical health **What could be done to improve outcomes/promote recovery among people with Psychosis\*\*?\*\*** - Better pharmacological and psychological interventions - Better implementation of the treatments we already have (1) - Improvements to teams and services (2) - Focus on service users' own definitions of recovery (3) - Focus on the social part of the biopsychosocial triad (4) **Routes to improving outcomes (1): Implementing what we already know to work** - Failure to implement models as intended or to deliver evidence-based interventions pervades mental health care: - E.g. \