A description of the Australian Early Psychosis Intervention Model and a proposal to establish a Pilot Early Psychosis Intervention Program in Bolivia.

Dr. Guillermo Rivera, MD, MHPS, PhD.

Victoria (Aus) Burden of Disease Study: Incident Years Lived with Disability rates per 1000 population by mental disorderFirst Episode of Psychosis typically commences in young people: as do many of the more serious mental disorders

AgendaEarly Intervention in psychosis: Aparadigmof care for young people The EPPIC ModelThe Current State of Psychosis Treatment in BoliviaArguments for early intervention in BoliviaProgramme OverviewSustainability

1. Early Intervention in Psychosis: Aparadigmof care for young people Early intervention in Psychosis is a paradigm of care for young people with a first episode psychosis and their families based on research and comprises three concepts:

Early detection of psychosis

Reduce the long duration of untreated psychosis

Importance of the first 3-5 years following onset (critical period) for later biological, psychological and social outcomes

Aims of an Early Intervention serviceReduce delays (& DUP) by:promoting early detection and collaborative engagement in the communityOptimise assessment & diagnosis by:Comprehensive Bio/psycho/social assessmentMaximise recovery by: providing integrated bio/psycho/social community Rx focus on functional as well as symptomatic factorsaddressing co-morbidity and treatment resistance earlyPrevent relapse by:ensuring assertive follow-up and psychoed. during critical period

Intervening to reduce the Duration of Untreated Psychosis (DUP)

FunctioningAgeProdrome2nd episode of psychosis16 First episode of psychosis2024Early detection & Crisis Assessment Team

Optimizing Inpatient Care and Treatment in Early Psychosis FunctioningAgeProdrome2nd episode of psychosis16 2024First episode of psychosis

FEP Inpatientservices

Intervening to Maximize Recovery & Prevent Relapse

FunctioningAgeProdrome2nd episode of psychosis16 2024Assertive follow-up Community TeamFirst episode of psychosis

Implications of delayed treatment

Greater decrease in functioning

Loss of educational opportunities

Impaired psychosocial and vocational development

Personal suffering/family burdens

Potential poorer response once treatment is provided

Greater costs

*Jackson, H. J., & McGorry, P. D. (2009).The recognition and management of early psychosis: a preventive approach. Cambridge University Press.

Development of Early Psychosis Programs

Melbourne, mid-80s Buckinghamshire, mid-80sNorth Birmingham UK early 90sGermany, 1990s (research1970s) USA & Canada, early 90s Scandinavia, mid-90sSwitzerland mid - 90sAmsterdam, late 90sAustralia late 90sUK 1999/2000Far East & South East Asia, 2001

Networks: IEPA & European FE Schizophrenia Network

Early Psychosis DeclarationWe need committed people, we need good-will people, we need grass-roots people.

this is a task for us all, each one with their possibilities and capabilities, but all together

A collaboration between NIMHE / Rethink, IRIS, the World Health Organisation and the International Early Psychosis Association

The Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne has pioneered early intervention in Australia for young people with psychosis.

Courtesy Orygen Youth Research Centre2. The EPPIC Model

South west Area4 sectorsInner West: (145,000)North West: (266,700)Mid west: (208,000)South West: (237,600)(Each sector has 20 CCU beds for long-stay patients)EPPIC1621212424= Acute adult= EPPIC bedsEPPIC serviceWestern Region of Melbourne (pop = 850,000)

Overview of Mental Health Services For Kids & YouthOlder Adolescent Service(follow-up to age 19)EPPIC(18 month follow-up)Youth Assessment TeamAcuteInpatientCareDayGroupProgramFamilyworkIntensiveOutreachSupportOutpatient Case ManagementWestern Region of Melbourne (800,000)Non-psychotic Ages 15 -19PsychoticAges 15-30CognitiveTherapiesPACEClinicProdrome

Specified aims of EPPICThe early identification and treatment of the primarysymptoms of psychotic illness.To improve access to, and reduce delays in, initial treatmentTo reduce the frequency and severity of relapses, and to increasethe time to a first relapseTo reduce secondary morbidity in the post-psychotic phase of illnessTo reduce the disruption to social and vocational functioning andpsychosocial development in the critical period following the onset ofillness, when most disability tends to accrueTo promote well-being among family members and reduce theburden for carers*

EPPIC provides a clinical service for up to 2 years to young people aged 15- 24 years living in the catchment area who have been diagnosed with a first episode of psychosis.EPPIC clinical work is provided in phases, according to the phase of illness. In a first episode of psychosis full recovery is possible with the appropriate multidisciplinary multi-faceted treatment. As treatment continues it needs to be tailored according to both the needs of the individual and their particular experience of the illness.

*Clinical Stagingof Psychosis

3. The Current State of Psychosis Treatment in Bolivia

Less than half of the more than 250 adolescents and young adults* who are estimated to experience a first episode of psychosis in the city of Santa Cruz each year are ever diagnosed and receive psychiatric treatment.Patients who are eventually recognized as having a first episode of psychosis are estimated to have experienced, on average, 2 years of symptomatology prior to diagnosis. At this stage, psychiatric treatment occurs most often in an inpatient setting and most frequently follows an episode of aggression that places the patient or others at risk for harm.Most psychiatric treatment occurs in inpatient psychiatric hospitals during lengthy stays, which in Santa Cruz are not publicly funded. Outpatient options are limited.

** Incidence estimate is based on World Health Organization incidence rates for schizophrenia spectrum diagnoses in 15-24 year olds.

BarriersThere is an especially strong stigma of mental illness throughout Bolivia.

Bolivia earmarked only 0.2% of its health budget for mental health. There arent public psychiatric facilities in Santa Cruz and all patients must pay out of pocket for a significant portion of their treatment

Bolivia has a especially low presence of psychiatrists, with an average of only 1 per 100,000 inhabitants

Informe de la Evaluacin de Salud Mental en Bolivia Usando el Instrumento de la Evaluacin de los Sistemas de Salud Mental de la OMS 2008.

Barriers 2There is a lack of mental health training for primary care health personnel. Limited ability to appropriately screen for, identify, and treat mental illnesses in the general population. Bolivia has a highly fragmented medical system. There are no electronic medical records. There is limited coordination of care between individual providers as well as between group providers, such as clinics and hospitals.

Informe de la Evaluacin de Salud Mental en Bolivia Usando el Instrumento de la Evaluacin de los Sistemas de Salud Mental de la OMS 2008.

4. Arguments for early intervention in Bolivia

It does not require significant investment in medical or physical infrastructure, technology or high-cost, hard-to-obtain medications. It does not rely heavily on psychiatrists, of whom the supply is limited in Bolivia, or on a large workforce of highly trained personnel. On a per patient basis, early intervention is far less costly than inpatient crisis treatment, which is the current de facto standard of psychiatric care for psychosis in this country. *

4. Arguments for early intervention in BoliviaOur proposed early psychosis intervention program represents a low-tech, appropriate and potentially very transferable technology.

Bolivia does simply not need more mental health care it needs a shift towards smarter, more strategically organized, more economical care and this programme would represent an important step in this direction.

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5. Programme OverviewA pilot early psychosis intervention program calledEl Programa de Apoyo Temprano a la Psicosis(PATAP) will provide age appropriate bio-psychosocial treatment and support for 15-25 years oldwith first episode psychosis and their families,who reside in the neighborhood of Plan 3000 in thecity of Santa Cruz de la Sierra, representing acatchment area of 350,000. *

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PATAPS AimsThis programs specific objectives are to: Improve short and long-term outcomes for those with psychosisIncrease speed of recoveryDecrease the need for hospitalizationReduce family disruptionDecrease rates of relapse

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Four Principal Components28

Attention and Treatment

Service Model Our programme will be implemented under a"radial" model basis, where primary care,responsibility and focus care program is in thehands of current and leading providers of mentalhealth services (the "spokes"), but the contributionof specialists is provided by a treatment team ofexperts dedicated to first episode (the "hub").

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31 The Hub

The Spokes

The team managerFull-time positionThe centralized Hub provides support for the spoke workers through the delivery of clinical supervision, training, administration and management.AdministratorFull-time positionConsultant PsychiatristPart-time positionConsultant PsychologistPart-time position

Social WorkerFull-time positionThe community location of the Spokes, provides excellent opportunity to encourage referrals from local primary, voluntary and generic youth services, thus reducing the DUP.Mental Health NursePart-time positionAssistant PsychologistPart-time positionAssistant PsychologistPart-time position

6. SustainabilityWe do believe that public funding for mental illness will increase over time, but it will take a significant, concerted, well organized, and consistent lobbying effort in order to make this change happen.We have already begun working with and providing support to the organization of family members of people with psychosis in the city of Santa Cruz. We will continue to work with this organization, training and providing support in order to optimize their lobbying efforts.

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What is currently most lacking in order to support any lobbying effort for improved mental health treatment in Santa Cruz is a programme such as we are proposing that would provide a model of what mental health treatment should actually look like.Anyone with psychosis, should have a right to expect the kind of comprehensive bio-psycho-social treatment that our program proposes. This is the argument that we believe we will be able to effectively make and communicate towards the public and lawmakers over time.

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Using terms often applied to sustainable development, early psychosis intervention programs represent an appropriate and potentially very transferable technology.Therefore, one of the principal goals of our programme will be to create a model or blueprint that might be replicated in similar communities across Bolivia beyond Santa Cruz and possibly in other developing countries.*

SummaryThis program includes an innovative outreach program that combines sound business principals with social goals in order to specifically target the largest barrier to early psychosis treatment in Bolivia: the stigma of mental illness.By utilizing a mobile, multidisciplinary treatment team that emphasizes the roles of trained case managers focused on providing intensive individual and family support in the home, this program will provide culturally appropriate care that will leverage contributions from a limited supply of psychiatrists and shift dependence away from a fragmented medical system.*

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