Early intervention in psychosis service and psychiatric admissions

AIMS AND METHOD

To investigate the effects of a standard National Health Serviceearly intervention in psychosis service on bed days and engagementwith services. We conducted a naturalistic before-and-afterstudy comparing outcomes of individuals who received treatmentfrom the service (n=75) with outcomes of individuals who presentedto mental health services before the early intervention servicewas established and received treatment as usual (n=114).

RESULTS

People treated by the early intervention in psychosis servicehad significantly fewer admissions (P<0.001), readmissions (P<0.001), total bed days (P<0.01) and better engagementwith services (P<0.05).

CLINICAL IMPLICATIONS

An early intervention in psychosis service compliant with currentBritish mental health policy led to reduced use of psychiatricbed days confirming recent findings elsewhere. This leads tomajor financial savings, easily justifying the initial costof investment in the service.

Introduction

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Introduction

The Mental Health Policy Implementation Guide (Department of Health, 2001) outlines how early intervention in psychosis services shouldfunction. At the time the guidelines were issued, there waslittle evidence for the effectiveness of these services (Pelosi & Birchwood, 2003)but evidence is now accumulating. The early onset randomisedcontrolled trial in Lambeth showed that assertive early interventionreduced the relapse and hospital readmission rates comparedwith usual community mental healthcare (Craig et al, 2004),improved service users’ social and vocational functioning,quality of life and medication adherence (Garety et al, 2006). Petersen et al (2005) found in a randomised trial that assertiveintegrated community treatment in Denmark compared with usualcommunity mental healthcare led to reduced bed days and improvedclinical outcomes and treatment adherence. In a Canadian study(Goldberg et al, 2006), in-patients with non-affective first-episodepsychosis were assessed before and after the introduction ofan early intervention in psychosis service. When early interventionwas used, there was a smaller number of hospital admissionsand reduced violent behaviour.

We used the same design in our study as Cullberg et al (2006),comparing a prospective group that received care from an earlyintervention psychosis service with a historical group thatreceived treatment as usual. The early intervention in psychosisservice was based on a hub and spoke model adapted from the Department of Health’s guidelines (Paxton et al, 2003) for a mixed urban/rural area. Some staff were based withincommunity mental health teams, but the service was functionallycompliant with the Department of Health’s guidelines.We aimed to replicate the emerging findings indicating theadvantages of early intervention in psychosis compared with usual care, and to investigate the effects on hospital readmission(generally the most expensive element of mental healthcare)and service users’ engagement with services.

Method

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Method

Participants
In September 2002, an early intervention in psychosis team wasestablished in Northumberland. The service aimed to take onall individuals with first-episode psychosis in the county.Participants were service users under 36 years of age who presentedbetween October 1998 and September 2005. The first group (n=114)were individuals who presented between October 1998 and September2002 (i.e. before the service had been established), but whowould have met the acceptance criteria for the service. Theother group (n=75) were all individuals who received treatmentfrom the service between September 2002 and October 2005 (Table 1).

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Table 1. Demographics

We compared the two groups using a ${chi}$ ²-test and found significantdifferences linked with a poor prognosis, male gender (Murray & Van Os, 1998), marital status (Farnia et al, 1963), and younger age at onset (Jablensky et al, 1992). This suggests a worse prognosis wouldbe expected in the group who received early intervention treatment.

Procedure
Data were obtained from the Population-Adjusted Clinical Epidemiology database (PACE; Proctor et al, 2004). The database recordedprospective information on the presentation, management andoutcomes of all individuals with first-episode psychosis inNorthumberland.

Participants were identified by consultant psychiatrists andreferred to the PACE team. The team gathered information ondemographics, ICD-10 diagnosis, hospital admissions, medication,contact status, risk assessment and use of services, but weused only patient information on demographics, hospital admissionsand employment status for the study. Data were gathered fromin-patient and out-patient secondary care medical notes at presentation and annually on a continuing basis. The PACE staff had no contactwith patients and were not involved in their care or management.They also screened the local National Health Service (NHS)computerised patient information system and sent monthly remindersto consultant psychiatrists to ensure comprehensive data.

Analysis
Data on 253 individuals were collected between October 1998and October 2005; 64 individuals were excluded from the mainanalysis as they did not meet the acceptance criteria for theearly intervention. Of the excluded service users, 20 presentedbefore the service had been established; 44 presented afterthat but were not accepted for treatment by the service. Theywere excluded for the following reasons: a diagnosis of borderlinepersonality disorder at any stage of follow-up; a predominantdiagnosis of organic psychosis across the 3-year follow-up;drug/alcohol-induced psychosis that did not persist 5 daysafter the intoxication; having moved out of area or transferredcare within the first year after referral; a diagnosis of bipolar disorder without psychotic symptoms.

Excluded service users were compared with those included inthe study to ensure that their exclusion did not bias the analysis.An analysis of variance (ANOVA) showed no significant differencesbetween the two groups.

We analysed differences between the groups in hospital bed usage, engagement with services, and as a possible confounding factor- differences in atypical antipsychotic medication.

Data were analysed using SPSS version 14.0 for Windows.

Results

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Results

Hospital admissions
We used a one-way between-groups ANOVA to see whether the early intervention had any effect on the service users’ numberof admissions in the first 3 years of receiving mental healthtreatment, the number of readmissions and the total numberof days in hospital (Table 2). There were significant differencesbetween the two groups in each case respectively: P<0.001[F (1, 187)=10.8], P<0.001 [F (1, 187)=9.2], P<0.01 [F(1, 187)=5.8].

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Table 2. Hospital admission data

Engagement with services
Engagement with services 1 year after first presentation wascompared in the two groups using a ${chi}$ ²-test (Table 3). The groupwho used the early intervention service were significantlymore likely to still be engaged with services at 1 year follow-up(P<0.05).

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Table 3. Engagement with services at one year

Discussion

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Discussion

This is the first naturalistic study to report significantlyimproved outcomes for individuals who used a standard NHS earlyintervention in psychosis service functionally compliant withthe Department of Health’s guidelines.

Comparison with previous research
Despite the recent inconclusive Cochrane review (Marshall & Rathbone, 2006)and the scarce number of available randomised controlled trials,several recent findings on the effectiveness of early interventionin psychosis services have been encouraging. The present studyconfirms the findings of Craig et al (2004) and Goldberg et al (2006) in demonstrating reduced bed days, and Petersenet al (2005) in demonstrating improved engagement. McCrone& Knapp (2007) have developed a model to estimate theeconomic impact of early intervention services and they have suggested that such services can save costs. In the presentstudy the savings on reduced bed days were significantly greaterthan the cost of operating the service - 4755 bed days weresaved in the early intervention. When multiplied by the trusttariff for an adult acute bed day (£258), this led toan estimated saving of £1226 790. The total cost of theservice was estimated at £804 122, giving a net savingof £422 668 over the period of the study. This does notinclude the treatment-as-usual costs of community mental healthteams and other elements.

The Northumberland early intervention in psychosis service coversan area of nearly 2000 square miles and has an expected incidenceof 30 new cases per year. The model of service delivery hadto be adapted - instead of the recommended specialist team,a hub and spoke model was used where care coordinators wereembedded within community mental health teams. As the servicedeveloped, more staff, including care coordinators, were embeddedin the hub. This is the first study to show the effectivenessof a hub and spoke model of early intervention in psychosisand that the service can be effectively delivered in ruralareas.

Limitations
There are some limitations owing to the service model and servicedesign. The PACE database selected 44 individuals that didnot meet the inclusion criteria for the early intervention;the early intervention group had to be retrospectively assessedto exclude those who would not have been accepted by the service.This suggests that the early intervention in psychosis team, which functioned according to the Department of Health’smodel, had narrower acceptance criteria and was targeted atthe more unwell. This is also supported by the significantdifferences in gender, age and marital status between the twogroups, which suggest that the early intervention group should have had a poorer prognosis.

The quasi-experimental design used here is vulnerable to potential confounding factors. One is a possible difference in prescribingof atypical antipsychotics between the two groups - in ourstudy, 85% of the early intervention group and 63% of the treatment-as-usualgroup were prescribed atypical antipsychotics as first-lineantipsychotic medication. We are not aware of any researchsuggesting that the use of atypical antipsychotics reducesbed days and so it is unlikely that their greater use in thefirst group affected the results.

Another possible confounding factor is the development of crisisresolution and home treatment services. In Northumberland itwas staged by both locality and function. In the west of Northumberland,a limited hours crisis service was operational throughout theperiod of our study (it only became a 24-h service in 2006).In the more densely populated south-east region, the service was developed in 1999 but only started operating for 24 h,7 days a week in 2005 (that is, during the last 16 months ofthe data collection for our study). Glover et al (2006) suggestedthat only the crisis resolution services operating in thislatter system have an effect on admissions for young people.This staged development may explain the low usage of crisisresolution services, with only 25% of the pre-early intervention group and 42% of the treatment-as-usual group using the crisisresolution service. Moreover, some researchers suggest thatthe crisis resolution service has limited effectiveness formen (Dean & Gadd, 1990; Schnyder et al, 1999) and peoplewith a functional psychosis (Schnyder et al, 1999; Guo et al, 2001;Abas et al, 2003). Thus, the limited development of crisisresolution service in Northumberland during the period of thisstudy and the evidence of its relative ineffectiveness withour main participant group (young men experiencing psychosis)make it unlikely that it was responsible for the highly encouragingresults reported.

Implications
The study has several important implications, although becauseof the limitations of the before/after design the findingsshould be interpreted with caution. Still, the results suggestthat early intervention in psychosis services based on theDepartment of Health’s guidelines can lead to significantcost savings. They are, alongside crisis resolution services,an ‘invest to save’ opportunity. More significantly,reducing hospital admissions which can often be traumatic (Morrison et al, 2003)is an important outcome for service users. The study supportsthe usefulness of the Mental Health Policy Implementation Guide,and shows that it can be modified successfully in a mixed urban/ruralarea using a hub and spoke model with the hub having a key rolein ensuring functional fidelity to the guidelines. We believethat this mechanism is crucial for effectiveness.

Randomised controlled trials remain the gold standard for researchon the effectiveness of different interventions. However, inthe absence of credible alternative intervention packages,the ethical difficulties in with-holding interventions withproven efficacy from the control group, then quasi-experimental,naturalistic designs can be of value.

References

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