Key Activities of an ARMS Key Activities of an ARMS ServiceService

Dr Samantha BoweDr Samantha BoweClinical Psychologist / Clinical Lead for EDIT Clinical Psychologist / Clinical Lead for EDIT

ServicesServicesBSTMH NHS TrustBSTMH NHS Trust

AcknowledgementsAcknowledgements

Salford EDIT TeamSalford EDIT Team

Dr Sophie ParkerDr Sophie Parker Maria KaltsiMaria Kaltsi

Clinical PsychologistClinical Psychologist Assistant PsychologistAssistant Psychologist

Rory ByrneRory Byrne Sarah FordSarah Ford

Service User RepresentativeService User Representative Assistant PsychologistAssistant Psychologist

Jane FosterJane Foster

PA/ Team SecretaryPA/ Team Secretary

Dr Paul French / Prof Tony MorrisonDr Paul French / Prof Tony Morrison

Associate Directors in Early InterventionAssociate Directors in Early Intervention

Identification Young People At-Risk Identification Young People At-Risk of Psychosisof Psychosis

Training with potential referrers to help recognise Training with potential referrers to help recognise ‘at-risk’ signs‘at-risk’ signs

Information: attenuated route / BLIPs / family route Information: attenuated route / BLIPs / family route / service delivery / leaflets for client/ service delivery / leaflets for client

Primary Care Checklist for guidancePrimary Care Checklist for guidance Assessment using specific ‘at-risk’ measure e.g. Assessment using specific ‘at-risk’ measure e.g.

CAARMSCAARMS Clear feedback to referrers of outcomeClear feedback to referrers of outcome

If physical signs consider

Substance abuse

Liver function abnormalities

Systemic infection

Nutritional deficiencies

CNS abnormalities

Metabolic disorders

Cardiac abnormalities

Drug toxicity

Primary Care Guidelines for Identification of Suspected or First Episode Psychosis

Checklist for Psychosis Scoring

The family is concernedExcess use of alcoholUse of street drugs (including cannabis)Arguing with friends and familySpending more time alone

………… One point each …………….

Sleep difficultiesPoor appetiteDepressive moodPoor concentrationRestlessnessTension or nervousnessLess pleasure from things

………… Two points each ………….

Feeling people are watching you *Feeling or hearing things that others cannot *

………… Three points each …………

Ideas of reference *Odd beliefs *Odd manner of thinking or speechInappropriate affectOdd behaviour or appearanceFirst degree family history of psychosisplus increased stress or deterioration infunctioning *

………… Five points each …………...

TWENTY POINTS OR MORE CONSIDER

REFERRAL

FOR ASSESSMENT .

____ ____ ____ ____ ____

Sub Total ____

____ ____ ____ ____ ____ ____ ____

Sub Total ____

____ ____

Sub Total ____

____ ____ ____ ____ ____

____

Sub Total ____

Final Total

If any * items areendorsed then considerreferral to EDIT even ifscore is less than 20

19.7.02 19.7.02

EDIT

0161 772 4350

EI team0161 745 2254

CMHT

Crisis Team

If immediate risk

Sub-threshold/uncertaindiagnosis

Clearly first episode psychosis

Referral PathwaysReferral PathwaysReferral SourceReferral Source No. ReferredNo. Referred Community Mental Heath TeamsCommunity Mental Heath Teams

Youth Offending TeamYouth Offending Team

Primary Care Psychology ServicesPrimary Care Psychology Services

General Practitioner (GP)General Practitioner (GP)

Early Intervention TeamEarly Intervention Team

Inpatient UnitInpatient Unit

Housing AgenciesHousing Agencies

ConnexionsConnexions

Crisis TeamCrisis Team

Drug ServicesDrug Services

Self ReferralSelf Referral

FamilyFamily

CAMHSCAMHS

Assertive OutreachAssertive Outreach

2626

1919

1717

77

77

77

66

55

44

44

22

22

22

11

Evidence Based InterventionsEvidence Based Interventions

Preventative approach with developing Preventative approach with developing evidence baseevidence base

Important to draw on evidence base so farImportant to draw on evidence base so far Not automatically replicate existing models Not automatically replicate existing models

& treatments used in mental health (e.g. & treatments used in mental health (e.g. CMHT / EI)CMHT / EI)

Different client group – often younger, not Different client group – often younger, not yet made transition :- ethical issuesyet made transition :- ethical issues

Evidence Based InterventionsEvidence Based Interventions

Cognitive TherapyCognitive Therapy Effective at preventing transition to psychosis Effective at preventing transition to psychosis Transition rates (12 months post CT): cognitive Transition rates (12 months post CT): cognitive

therapy: 6%therapy: 6% monitoring alone: 22%monitoring alone: 22% If no intervention at all: Yung et al. (1998) – 40%@ If no intervention at all: Yung et al. (1998) – 40%@

6mths 6mths Salford EDIT 2006-2007: 8% transition rateSalford EDIT 2006-2007: 8% transition rate Evidence base for psychosis, anxiety, depression Evidence base for psychosis, anxiety, depression

etc. Helpful for false positive group.etc. Helpful for false positive group.

Evidence Based InterventionsEvidence Based Interventions

Collaborative, normalising, individual Collaborative, normalising, individual problem list & goals, formulation to inform problem list & goals, formulation to inform intervention strategies.intervention strategies.

Acceptable intervention for clients: low drop Acceptable intervention for clients: low drop out rate in EDIE Iout rate in EDIE I

Drop Out RatesDrop Out Rates

0

10

20

30

40

50

60

PACE EDIE PRIME

% o

f dr

opou

ts

McGorry et al. 2002

[CBT plus risperidone]

McGlashan et al. 2006

[Olanzapine]

Morrison et al. 2004

[CT]

Case ManagementCase Management

Social difficulties increase risk of psychosis Social difficulties increase risk of psychosis & other mental health problems & other mental health problems

Case management located in EDITCase management located in EDIT Promotes engagementPromotes engagement Assist & promote use of mainstream Assist & promote use of mainstream

services (e.g. housing, benefit agencies, services (e.g. housing, benefit agencies, connexions). Balance help with promoting connexions). Balance help with promoting independence.independence.

Anti-Psychotic MedicationAnti-Psychotic Medication

Lack of evidence base so far Lack of evidence base so far PRIME study: McGlashen et al. (2003)PRIME study: McGlashen et al. (2003) olanzapine 5-15mg a day for 1 year, 12 mth follow olanzapine 5-15mg a day for 1 year, 12 mth follow

upup Transition rates: olanzapine = 16 %Transition rates: olanzapine = 16 % placebo = 37%placebo = 37% Side effects / ethical issuesSide effects / ethical issues If not effective, less compliance if make transition?If not effective, less compliance if make transition? Follow International Clinical Practice Guidelines for Follow International Clinical Practice Guidelines for

Early Psychosis (2005) Early Psychosis (2005)

Anti-Psychotic MedicationAnti-Psychotic Medication

Anti-psychotics not usually indicated unless Anti-psychotics not usually indicated unless person meets criteria for psychosisperson meets criteria for psychosis

Exceptions: severe suicidal risk, rapid Exceptions: severe suicidal risk, rapid deterioration, treatment of depression ineffective, deterioration, treatment of depression ineffective, aggression poses risk to othersaggression poses risk to others

Low dose for trial periodLow dose for trial period EDIT: if prescribed anti-psychotic contact referrer EDIT: if prescribed anti-psychotic contact referrer

to discuss rationale / info. packsto discuss rationale / info. packs Training slot: SPR’s in Trust: info. packs / Training slot: SPR’s in Trust: info. packs /

International Clinical Practice GuidelinesInternational Clinical Practice Guidelines

MonitoringMonitoring

Regularly repeat assessment measures Regularly repeat assessment measures to Ensure effectiveness of interventions & monitor to Ensure effectiveness of interventions & monitor

mental state over timemental state over time Monitoring offered up to 3 years even if not Monitoring offered up to 3 years even if not

engaged with other aspects of serviceengaged with other aspects of service Reduce DUPReduce DUP If at-risk at monitoring appt. – booster sessions / or If at-risk at monitoring appt. – booster sessions / or

increase contactincrease contact Flexible: consent for face to face contact / phone Flexible: consent for face to face contact / phone

or e-mail etc.or e-mail etc.

Duration Of Untreated PsychosisDuration Of Untreated Psychosis

Greater length of time between onset of Greater length of time between onset of psychosis & receiving treatment the worse psychosis & receiving treatment the worse the prognosisthe prognosis

Average DUP 1 year (Barnes et al. 2000)Average DUP 1 year (Barnes et al. 2000) ARMS service can reduce DUPARMS service can reduce DUP EDIT: 25% referred onto to EI with EDIT: 25% referred onto to EI with

undetected first episode psychosisundetected first episode psychosis

Service User InvolvementService User Involvement

Service user feedbackService user feedback EDIT: Service User Representative – EDIT: Service User Representative –

consultancy role on service developmentconsultancy role on service development

- interview panel for recruitment- interview panel for recruitment

- service user forum / research- service user forum / research

- someone clients to speak to when deciding - someone clients to speak to when deciding whether or not to be seen for assessment or whether or not to be seen for assessment or therapytherapy

Interface with ServicesInterface with Services

Ensure effective interface between servicesEnsure effective interface between services e.g. primary care, EI, CMHT’s, voluntary e.g. primary care, EI, CMHT’s, voluntary

sector, A&E, CAMHS etc.sector, A&E, CAMHS etc. Co-working: clear guidelines written into Co-working: clear guidelines written into

protocols (e.g. CAMHS, EI)protocols (e.g. CAMHS, EI) EDIT: primary care, link into established EDIT: primary care, link into established

services when appropriate (e.g. A&E, services when appropriate (e.g. A&E, CMHT’s, EI etc)CMHT’s, EI etc)

Responsive to risk Responsive to risk

Family InvolvementFamily Involvement

Involvement of family / significant others for Involvement of family / significant others for support & advicesupport & advice

With clients consent: regular feedback, With clients consent: regular feedback, psycho education, sharing of formulation, psycho education, sharing of formulation, advice on how best to help, crisis plans / advice on how best to help, crisis plans / emergency no’semergency no’s

Family intervention if appropriateFamily intervention if appropriate

Awareness Raising Awareness Raising

Awareness raising & education about psychosis in Awareness raising & education about psychosis in primary care, social care, voluntary sector, & primary care, social care, voluntary sector, & educationeducation

Mental health promotional work in schools, Mental health promotional work in schools, colleges etc.colleges etc.

De-stigmatise psychosis: challenge De-stigmatise psychosis: challenge misconceptions (increase likelihood of disclosure misconceptions (increase likelihood of disclosure & positive response) & positive response)

EDIT: currently providing staff training on range of EDIT: currently providing staff training on range of mental health problems, not just on early signs of mental health problems, not just on early signs of psychosispsychosis

Core PrinciplesCore Principles

Culture, age & gender sensitiveCulture, age & gender sensitive - 66% clients in EDIT under 21 yrs- 66% clients in EDIT under 21 yrs

Service user & family focusedService user & family focused - collaborative approach, individually tailored, based on clients’ - collaborative approach, individually tailored, based on clients’

‘problem list’ & goals‘problem list’ & goals - family involvement- family involvement

Meaningful engagement based on assertive Meaningful engagement based on assertive outreach modeloutreach model

- home visits, do not discharge due to non attendance, open door - home visits, do not discharge due to non attendance, open door policy, flexible approach: e-mail, text etc. policy, flexible approach: e-mail, text etc.

Core PrinciplesCore Principles Low use of stigmatising settingsLow use of stigmatising settings (youth friendly, age appropriate, primary care settings, (youth friendly, age appropriate, primary care settings,

home visits)home visits) - Fear of going mad common – important to keep in - Fear of going mad common – important to keep in

primary care (if see within a MDT setting: can be primary care (if see within a MDT setting: can be frightening, increase distress, effect engagement)frightening, increase distress, effect engagement)

- Service delivery in primary care setting (EDIT & GP) - Service delivery in primary care setting (EDIT & GP) unless significant risk issues which require co-working with unless significant risk issues which require co-working with other servicesother services

Recovery based principles: Recovery based principles: - - meaningful activitiesmeaningful activities - valid social roles (college, work, relationships)- valid social roles (college, work, relationships)

Summary: Core FeaturesSummary: Core Features

Raise Awareness /

EducationStigma

Reduce DUP

Prevent Transition to

Psychosis

ARMS Service

Summary: Core FeaturesSummary: Core Features

Family Involvement

Case Management

MonitoringUp to 3 years

Evidence Based

Interventions

Specialist Assessment

ARMS client

Summary: Core FeaturesSummary: Core Features

Primary Care Setting

Good Interface with

Other Services

Recovery Focused

PIGCompliant

ARMS Service

Service User QuotesService User Quotes

““Like this psychology session, I mean if I had to go Like this psychology session, I mean if I had to go out and come to see everybody, the psychologist out and come to see everybody, the psychologist and things like that, I wouldn’t go out of the house and things like that, I wouldn’t go out of the house and that’s why I never got no where for years, but and that’s why I never got no where for years, but when the counsellor did get me in touch with the when the counsellor did get me in touch with the psychologist, I knew I’d stick with them because psychologist, I knew I’d stick with them because they’d do home visits, because I don’t go out and I they’d do home visits, because I don’t go out and I need help, but I need someone to come to me need help, but I need someone to come to me because I can’t do it”. because I can’t do it”.

Service User QuotesService User Quotes

‘‘like a dark cloud over your head, you can’t even like a dark cloud over your head, you can’t even sleep at night, just there thinking someone is going sleep at night, just there thinking someone is going to come, I thought I was in a movie, I’m dreaming, to come, I thought I was in a movie, I’m dreaming, but it’s not a dream’ but it’s not a dream’

‘‘well, before I started to cut meself I’d think, “god, well, before I started to cut meself I’d think, “god, they’re just doing it for attention” but until you are they’re just doing it for attention” but until you are actually in that situation you don’t understand what actually in that situation you don’t understand what they are going through …you understand more they are going through …you understand more then. You look at it in a different way’then. You look at it in a different way’

Service User QuotesService User Quotes

‘‘if you have someone like that to talk to it’s a lot more if you have someone like that to talk to it’s a lot more helpful than if you don’t helpful than if you don’t because if you don’t you’re just because if you don’t you’re just thinking you’re going really mad’thinking you’re going really mad’

‘‘basically you’re just going over the same thought, you’re basically you’re just going over the same thought, you’re going “am I crazy?” and going “am I crazy?” and then you’re going “well, I’m not” then you’re going “well, I’m not” and it’s just a big circle and then you’re conflicting and it’s just a big circle and then you’re conflicting with with yourself but if you have someone there they can explain, yourself but if you have someone there they can explain, like you say it to like you say it to them, they come back with a different them, they come back with a different answer, they don’t come back with the same answer, they don’t come back with the same one that one that you think all the time and it changes the circle, it changes you think all the time and it changes the circle, it changes the pattern’the pattern’

Service User QuotesService User Quotes

‘‘yeah, I was like bubbly and confident and not shy and stuff yeah, I was like bubbly and confident and not shy and stuff like that. Because like that. Because when I started to first cut meself I was when I started to first cut meself I was losing all me confidence when I was losing all me confidence when I was depressed and I depressed and I didn’t want to go out, I didn’t want to do me hair, I just didn’t want to go out, I didn’t want to do me hair, I just wanted to wanted to stay in bed all day and that was when I kept stay in bed all day and that was when I kept on cutting meself and then like I’d been on cutting meself and then like I’d been on anti on anti depressants for a bit, (therapist) came here a few times, depressants for a bit, (therapist) came here a few times, spoke to her, it was spoke to her, it was just all coming back, all me confidence just all coming back, all me confidence coming back, just getting back to normal, how I used to be coming back, just getting back to normal, how I used to be like before, y’know before it all started,’like before, y’know before it all started,’

‘‘I’m proud of myself, I’m very proud of myself, oh my God, I’m proud of myself, I’m very proud of myself, oh my God, I’ve done good, it’s not easy, you know that’I’ve done good, it’s not easy, you know that’

ReferencesReferences

Parker, S., French, P., Kilcommons, A., & Shiers, D. Parker, S., French, P., Kilcommons, A., & Shiers, D. (2007). Report on Early Detection and Intervention for (2007). Report on Early Detection and Intervention for Young People at Risk of Psychosis.Young People at Risk of Psychosis.

Parker, S. & French, P. (2007). Implementation Guide.Parker, S. & French, P. (2007). Implementation Guide.

Hardy, K. & Morrison, A. P. 2007. The journey into and Hardy, K. & Morrison, A. P. 2007. The journey into and through EDIT - a qualitative exploration of the experiences through EDIT - a qualitative exploration of the experiences of our clients. Unpublished Doctorate Thesis. University of of our clients. Unpublished Doctorate Thesis. University of Liverpool.Liverpool.

Contact DetailsContact Details

samantha.bowe@bstmht.nhs.uksamantha.bowe@bstmht.nhs.uk

Dr Samantha BoweDr Samantha Bowe

Clinical Psychologist / Clinical Lead for EDIT ServicesClinical Psychologist / Clinical Lead for EDIT Services

0161 772 43500161 772 4350