Transcript AUDIT Sheffield 1.6.04 – 31.5.04

City-Wide Audit:
Incidence of First Episode Psychosis,
Duration of Untreated Psychosis and
Demographics
Principal Authors: Rob McFarland (Research Assistant), Dr Jo
Nicholson (Clinical Psychologist - Research Lead), Rachel
Simmonds (Assistant Psychologist) and Steve Day (Practice
Development Lead, Early Intervention)
Contributing Authors: Dr Mary Hamilton (Consultant Psychiatrist Early Intervention), Guy Hollingsworth (Service Director) and
Eileen MacDonald (West PCT)
Context 1- Rationale for Early Intervention
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Delay between onset of psychotic symptoms and first treatment is usually
between one to two years.
The longer the individual remains untreated, the greater the opportunity for
serious physical, social or legal harm
The period of untreated psychosis has been shown to involve distress for
individuals and their relatives including ineffective and demoralising
attempts to get help.
Where disabilities develop, in either social or personal function, they usually
do so in the first three years – ‘the critical period’
Unemployment, impoverished social networks, loss of self-esteem will all
develop most aggressively during the critical period
Long duration of psychosis prior to treatment has consistently been shown
to be related to poor outcome
Giving neuroleptic treatment early improves outcome
Providing treatment early on improves the long-term course of psychosis
and reduces the longer-term health care costs
Early treatment reduces the development of longer term ‘treatment resistant’
symptoms and the ‘revolving door’ syndrome of marked repeated relapse
10% of all disabled people = psychosis
45% total NHS direct care budget
Context 2 – Service Development
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North PCT - (slim) pilot EIS
South West PCT – EIS from
West PCT – EIS from
South East PCT - EIS from
since 2001
January 2005
January 2005
May 2005
• TARGETS
• Service Caseload
• Reduce Duration of Untreated
Psychosis (DUP)
• EI in psychosis is ….
Audit Method - 1
• Audit covers 1 year period - June 2004 to May
2005
Inclusion Criteria:
• Young people (age 16-35) referred to Secondary
Mental Health Services with either diagnosis of
psychosis or strong suspicion of psychosis
• Primary diagnosis of mood disorder or learning
disability excluded
• Co-morbidity of substance misuse included
• Referred within last 2 months
Audit Method -2
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Audit covers 1 year period - June 2004 to May 2005
Seeking all clients referred to secondary MH services
Existing psychiatric notes were interrogated for all patients meeting
inclusion criteria
Duration of untreated psychosis (DUP) calculated as:
Length of time from onset of psychosis to onset of treatment
30
Frequency
20
10
0
not enough
data
poor: significant
adequate1:
adequate2:
gaps and
no/few gaps
overall good
lack of detail
but detail limited detail but some
gaps
good: no gaps
and good
detail
Incidence
• StHA estimate - 75 new cases per year
• Birmingham estimate - 214 new cases per
year
• Sheffield City Wide Audit - observed rate
in 1 year period 105 cases
Basic Demographics
Sheffield Population
Comparison Data
At onset;
Age at onset
21.5 years
23.2 years
Gender
73% Male
76% Male
Ethnicity
38.1% BEMs
57.1% BEMs
Civil Status
88% Single
76% Single
Living
Circumstances
21% Living alone
Not reported
26% Living with non-relatives
Employment
46% Unemployed
26% Students
Not reported
Education
38% University/Higher
Education
Not reported
Ethnicity – 38% BEM
100
91.23
80
60
61.9
Psychosis Incidence Sheffield
40
20
0
Resident Population Sheffield
16.7
10.7
4.56 1.78 4.81.6 60.83
White Asian Black Mixed Other
It should also be noted that the data obtained from local NHS databases may not be completely accurate.
It appeared that although the majority of white client’s ethnicity had been inputted into the system, the
ethnicity of non-white clients were missing in a number of cases. This may have resulted in an under
representation of ethnic and black minorities recorded in the audit.
What happened between onset &
baseline?
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Changed accommodation – 38%
28% moved in with relatives
11% moved out from relatives to live alone
50% of workers became unemployed
13% of students became unemployed
Clinical Demographics - 1
• Diagnosis was not clearly recorded in the
majority of cases
• Hospitalised – 37% of which:
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Use of MHA during first admission – 60%
Use of MHA at any point in admission - 76%
Mean age at first admission– 23 (16-35)
Mean admission length – 42 days (1-229)
Police involved in first admission – 26%
Clinical Demographics - 2
• Forensic Hx Ever – 39%
Of which nearly ½ identified as related to their MH
• Self Harm Ever – 44%
Of which
35% multiple methods
63% within past 6 months
• Alcohol use in past month – 72%
• Drug use Ever - 81%
Of which
55% polyuse
Most commonly used drugs - 82% cannabis, 37% ecstasy, 31%
amphetamines, 22% cocaine
• Drug use in past month – 31%
Medication at Baseline
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Antipsychotic – 72%
Antidepressant -37%
Benzodiazepine – 32%
Mood stabilizer – 2%
More than one of these – 27%
No medication – 20%
Duration of Untreated Psychosis
Able to calculate DUP in 65% of cases:
• Mean DUP – 7½ months
• DUP range – 0 days - 7 years
• Statistically significant difference between men (x= 8½
months) and women (x=5½ months)
• No statistically significant difference for ethnicity,
hospitalisation, illicit drug use, marital status, education
• However, clinical points of interest - Longer DUP
observed if:
living with non-relatives or alone, unemployed, never used drugs,
married
• Complex interplay between living circumstances and
employment status
Age at onset of psychosis
Home address at onset on deprivation map:
(+ 8 outside Sheffield)
Conclusions
• Clinical governance issues addressed re: case note quality
• Observed incidence of 105 cases in 1 year period - less than
the estimate funding is based upon, need continued
monitoring over ‘reasonable’ time scale
• Basic Demographics - Male, BME, student, unemployed, LD
• Clinical Demographics - Self harm, forensic Hx, hospital, MHA
• People move accommodation and lose jobs in DUP period
• DUP & hospitalisation better than national average – but not
very good
• Broad similarity with comparison sample
• FERN – is EIS working?
• Research project provides more robust information as
presented within this data set ++ includes additional
information relating to pathways to care, detailed cased
vignettes
Sheffield Early Intervention Service
Netherthorpe House
101 Netherthorpe rd
Sheffield S3 7EZ
[email protected]
0114 226 4851
www.strangedays.org.uk