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NIHR Signal Education and the offer of support help GPs spot early signs of psychosis

Published on 14 June 2016

doi: 10.3310/signal-000251

The Liaison with Education and General Practices (LEGS) trial found that a tailored education session doubled the early identification and referral of people with, or at risk of, psychotic illness compared to a postal educational campaign or practice as usual.

An allocated mental health professional provided the session to each GP practice and repeated it one year later, in addition to offering ongoing access to them for support and advice.

It was also the most cost-effective intervention mainly due to the potential for subsequent savings from prevention of people developing more severe illness.

Wider implementation of an educational and liaison intervention such as this would be dependent on uptake and engagement of GPs, which was found to be a major barrier in this study.

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Why was this study needed?

Psychotic disorders such as schizophrenia cause enormous disability and are very expensive for families and society. People with severe mental illness experience an average 25-year shorter life expectancy compared with the general population. The annual cost of schizophrenia alone in England is £6.7 billion. Early intervention services identify and treat people with first episode psychosis or mental states putting them at high risk of developing psychosis with the aim of improving outcomes and possibly preventing more serious disease and disability.

This NIHR funded research programme focused on improving identification and prompt referral of people with first episode psychosis and high risk mental states to early intervention services. The programme included an epidemiologic study that was used to create a prediction tool called PsyMaptic which can estimate the number of people likely to have a first episode psychosis. This is being used by NHS England to support policies on early intervention service waiting times. The programme also included the LEGS trial evaluating the effect of educating GPs to help them identify young people at risk of developing psychosis and refer them to specialist care.

What did this study do?

An important component of the programme was the LEGS trial, a cluster randomised controlled trial. Twenty-four GP practices were randomised to a “high-intensity” intervention which involved a specialist mental health professional providing a one hour educational session at each GP practice, a booster session one year later and ongoing liaison and support. In addition, guidelines were sent in the post twice per year to help with the identification and referral of people with early signs of psychosis. Twenty-eight GP practices were randomised to a “low-intensity” intervention in which they just received the guidelines. The remaining fifty practices that had declined to participate continued with their usual care. Limitations of the study include the non-randomised usual care group, monetary incentive for the high-intensity group and non-inclusion of 17% of referrals in the analysis. They were excluded because they declined clinical assessment so diagnosis could not be confirmed, but this is a commonly encountered problem in this area.

What did it find?

After adjusting the results for surgery size and the number of GPs:

  • The high-intensity practices referred nearly double the number of people with suspected first episode psychosis than low-intensity practices or the usual care practices over the two years of the study (mean 1.25 people per practice [standard deviation (SD) 1.2] versus 0.7 people per practice [SD 0.9]). The high-intensity practices also referred more people at high risk of psychosis compared with the low-intensity practices although the difference was not statistically significant (mean 0.9 people per practice [SD 1.0] versus 0.5 people per practice [SD 1.0]).
  • When combining those with suspected first episode psychosis and those at high risk, the high-intensity practices referred double the number of people who went on to meet the diagnostic criteria, true positives (mean 2.2 people [SD 1.7] versus 1.1 people [SD 1.7]). They also referred more than double the number of people who did not meet the criteria, false positives, compared with the low-intensity practices (mean 2.3 people [SD 2.4] versus 0.9 people [SD 1.2]). However, the majority of the false positives, 68% required other mental health services.
  • Referral patterns did not differ between the low-intensity and “practice as usual” GP practices.
  • A cost-benefit analysis found the high-intensity intervention the most cost-effective strategy mainly as a result of fewer people at high risk or with first episode psychosis being missed and the potential subsequent savings from treatment costs. In the two year period, total cost per true positive referral was £26,785 for high-intensity practices, £27,840 for low-intensity and £30,007 for usual care practices.

What does current guidance say on this issue?

The 2014 NICE guideline on psychosis and schizophrenia in adults recommends that people who are distressed, have a decline in social functioning and have a familial risk or display symptoms or behaviour suggestive of psychosis should be referred by their GPs. An assessment should be performed without delay by a specialist mental health service or an early intervention in psychosis service because they may be at increased risk of developing psychosis. The guideline also recommends that early intervention in psychosis services should be accessible to all people with a first episode of psychosis, irrespective of the person's age or the duration of untreated psychosis.

The 2013 NICE guideline on psychosis and schizophrenia in children and young people also recommends that people with psychotic symptoms or other experiences suggestive of possible psychosis should be referred for assessment without delay. This could be to either a specialist mental health service such as Child and Adolescent Mental Health Services or an early intervention in psychosis service (14 years or over).

What are the implications?

The educational intervention supports GPs to implement NICE guidance. The trial showed that a tailored education session from a mental health specialist for GPs doubled the number of referrals of people with first episode psychosis and was more cost-effective than a postal campaign or practice as usual. Though there was also a higher rate of referral of people who did not go on to have a diagnosis of psychosis, the majority of cases did require referral to other mental health services.

In this study, the educational session was provided by either a psychologist, social worker or a nurse. In theory this means it could be replicated by mental health teams across the country, though it is unclear how much training may be required and the exact nature of the education as it was tailored per practice. The resource allocation could be calculated based solely on providing education sessions as the liaison services they also offered in this study were only rarely used by the GPs. It is not known how regularly the sessions need to take place or how to improve engagement with GP practices in more deprived areas where the rate of psychosis is higher and GPs may be busier and so less willing to engage with the intervention.

Citation and Funding

Perez J, Russo DA, Stochl J, et al. Understanding causes of and developing effective interventions for schizophrenia and other psychoses. Programme Grants Appl Res. 2016;4(2).

Perez J, Jin H, Russo DA, et al. Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial. Lancet Psychiatry. 2015;2(11):984-93.

Funding for this study was provided by the Programme Grants for Applied Research programme of the National Institute for Health Research.

Bibliography

NHS England. Guidance to support the introduction of access and waiting time standards for mental health services in 2015/16. London: NHS England; 2015.

NICE. Psychosis and schizophrenia in children and young people: recognition and management – guidance. [CG155]. London: National Institute for Health and Care Excellence; 2013.

NICE. Psychosis and schizophrenia in adults: prevention and management. [CG178] London: National Institute for Health and Care Excellence; 2014.

Royal College of Psychiatrists. No health without public mental health: the case for action. London: Royal College of Psychiatrists; 2010.

Why was this study needed?

Psychotic disorders such as schizophrenia cause enormous disability and are very expensive for families and society. People with severe mental illness experience an average 25-year shorter life expectancy compared with the general population. The annual cost of schizophrenia alone in England is £6.7 billion. Early intervention services identify and treat people with first episode psychosis or mental states putting them at high risk of developing psychosis with the aim of improving outcomes and possibly preventing more serious disease and disability.

This NIHR funded research programme focused on improving identification and prompt referral of people with first episode psychosis and high risk mental states to early intervention services. The programme included an epidemiologic study that was used to create a prediction tool called PsyMaptic which can estimate the number of people likely to have a first episode psychosis. This is being used by NHS England to support policies on early intervention service waiting times. The programme also included the LEGS trial evaluating the effect of educating GPs to help them identify young people at risk of developing psychosis and refer them to specialist care.

What did this study do?

An important component of the programme was the LEGS trial, a cluster randomised controlled trial. Twenty-four GP practices were randomised to a “high-intensity” intervention which involved a specialist mental health professional providing a one hour educational session at each GP practice, a booster session one year later and ongoing liaison and support. In addition, guidelines were sent in the post twice per year to help with the identification and referral of people with early signs of psychosis. Twenty-eight GP practices were randomised to a “low-intensity” intervention in which they just received the guidelines. The remaining fifty practices that had declined to participate continued with their usual care. Limitations of the study include the non-randomised usual care group, monetary incentive for the high-intensity group and non-inclusion of 17% of referrals in the analysis. They were excluded because they declined clinical assessment so diagnosis could not be confirmed, but this is a commonly encountered problem in this area.

What did it find?

After adjusting the results for surgery size and the number of GPs:

  • The high-intensity practices referred nearly double the number of people with suspected first episode psychosis than low-intensity practices or the usual care practices over the two years of the study (mean 1.25 people per practice [standard deviation (SD) 1.2] versus 0.7 people per practice [SD 0.9]). The high-intensity practices also referred more people at high risk of psychosis compared with the low-intensity practices although the difference was not statistically significant (mean 0.9 people per practice [SD 1.0] versus 0.5 people per practice [SD 1.0]).
  • When combining those with suspected first episode psychosis and those at high risk, the high-intensity practices referred double the number of people who went on to meet the diagnostic criteria, true positives (mean 2.2 people [SD 1.7] versus 1.1 people [SD 1.7]). They also referred more than double the number of people who did not meet the criteria, false positives, compared with the low-intensity practices (mean 2.3 people [SD 2.4] versus 0.9 people [SD 1.2]). However, the majority of the false positives, 68% required other mental health services.
  • Referral patterns did not differ between the low-intensity and “practice as usual” GP practices.
  • A cost-benefit analysis found the high-intensity intervention the most cost-effective strategy mainly as a result of fewer people at high risk or with first episode psychosis being missed and the potential subsequent savings from treatment costs. In the two year period, total cost per true positive referral was £26,785 for high-intensity practices, £27,840 for low-intensity and £30,007 for usual care practices.

What does current guidance say on this issue?

The 2014 NICE guideline on psychosis and schizophrenia in adults recommends that people who are distressed, have a decline in social functioning and have a familial risk or display symptoms or behaviour suggestive of psychosis should be referred by their GPs. An assessment should be performed without delay by a specialist mental health service or an early intervention in psychosis service because they may be at increased risk of developing psychosis. The guideline also recommends that early intervention in psychosis services should be accessible to all people with a first episode of psychosis, irrespective of the person's age or the duration of untreated psychosis.

The 2013 NICE guideline on psychosis and schizophrenia in children and young people also recommends that people with psychotic symptoms or other experiences suggestive of possible psychosis should be referred for assessment without delay. This could be to either a specialist mental health service such as Child and Adolescent Mental Health Services or an early intervention in psychosis service (14 years or over).

What are the implications?

The educational intervention supports GPs to implement NICE guidance. The trial showed that a tailored education session from a mental health specialist for GPs doubled the number of referrals of people with first episode psychosis and was more cost-effective than a postal campaign or practice as usual. Though there was also a higher rate of referral of people who did not go on to have a diagnosis of psychosis, the majority of cases did require referral to other mental health services.

In this study, the educational session was provided by either a psychologist, social worker or a nurse. In theory this means it could be replicated by mental health teams across the country, though it is unclear how much training may be required and the exact nature of the education as it was tailored per practice. The resource allocation could be calculated based solely on providing education sessions as the liaison services they also offered in this study were only rarely used by the GPs. It is not known how regularly the sessions need to take place or how to improve engagement with GP practices in more deprived areas where the rate of psychosis is higher and GPs may be busier and so less willing to engage with the intervention.

Citation and Funding

Perez J, Russo DA, Stochl J, et al. Understanding causes of and developing effective interventions for schizophrenia and other psychoses. Programme Grants Appl Res. 2016;4(2).

Perez J, Jin H, Russo DA, et al. Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial. Lancet Psychiatry. 2015;2(11):984-93.

Funding for this study was provided by the Programme Grants for Applied Research programme of the National Institute for Health Research.

Bibliography

NHS England. Guidance to support the introduction of access and waiting time standards for mental health services in 2015/16. London: NHS England; 2015.

NICE. Psychosis and schizophrenia in children and young people: recognition and management – guidance. [CG155]. London: National Institute for Health and Care Excellence; 2013.

NICE. Psychosis and schizophrenia in adults: prevention and management. [CG178] London: National Institute for Health and Care Excellence; 2014.

Royal College of Psychiatrists. No health without public mental health: the case for action. London: Royal College of Psychiatrists; 2010.

Understanding causes of and developing effective interventions for schizophrenia and other psychoses

Published on 1 March 2016

Perez J, Russo DA, Stochl J, Shelley GF, Crane CM, Painter M, Kirkbride JB, Croudace TJ, Jones PB

Programme Grants for Applied Research Volume 4 Issue 2 , 2016

Background Early-intervention services (EISs) offer prompt and effective care to individuals with first-episode psychosis (FEP) and detect people at high risk (HR) of developing it. Aims We aimed to educate general practitioners about psychosis and guide their referrals to specialist care; investigate determinants of the transition of HR to FEP; and predict numbers of new cases to guide policy and service planning. Incidence of psychosis in socially and ethnically diverse settings We studied the incidence of new referrals for psychosis in a well-established EIS called CAMEO [see www.cameo.nhs.uk (accessed 18 January 2016)] and built on other epidemiological studies. The overall incidence of FEP was 45.1 per 100,000 person-years [95% confidence interval (CI) 40.8 to 49.9 per 100,000 person-years]. This was two to three times higher than the incidence predicated by the UK Department of Health. We found considerable psychosis morbidity in diverse, rural communities. Development of a population-level prediction tool for the incidence of FEP We developed and validated a population-level prediction tool, PsyMaptic, capable of accurately estimating the expected incidence of psychosis [see www.psymaptic.org/ (accessed 18 January 2016)]. The Liaison with Education and General practiceS (LEGS) trial to detect HR We tested a theory-based intervention to improve detection and referral of HR individuals in a cluster randomised controlled trial involving primary care practices in Cambridgeshire and Peterborough. Consenting practices were randomly allocated to (1) low-intensity liaison with secondary care, a postal campaign to help with the identification and referral of individuals with early signs of psychosis, or (2) the high-intensity theory-based intervention, which, in addition to the postal campaign, included a specialist mental health professional to liaise with each practice. Practices that did not consent to be randomised included a practice-as-usual (PAU) group. The approaches were implemented over 2 years for each practice between April 2010 and October 2013. New referrals were stratified into those who met criteria for HR/FEP (together: psychosis true positives) and those who did not fulfil such criteria (false positives). The primary outcome was the number of HR referrals per practice. Referrals from PAU practices were also analysed. We quantified the cost-effectiveness of the interventions and PAU using the incremental cost per additional true positive identified. Of 104 eligible practices, 54 consented to be randomised. Twenty-eight practices were randomised to low-intensity liaison and 26 practices were randomised to the high-intensity intervention. Two high-intensity practices withdrew. High-intensity practices referred more HR [incidence rate ratio (IRR) 2.2, 95% CI 0.9 to 5.1; p = 0.08], FEP (IRR 1.9, 95% CI 1.05 to 3.4; p = 0.04) and true-positive (IRR 2.0, 95% CI 1.1 to 3.6; p = 0.02) cases. High-intensity practices also referred more false-positive cases (IRR 2.6, 95% CI 1.3 to 5.0; p = 0.005); most (68%) of these were referred on to appropriate services. The total costs per true-positive referral in high-intensity practices were lower than those in low-intensity or PAU practices. Increasing the resources aimed at managing the primary–secondary care interface provided clinical and economic value. The Prospective Analysis of At-risk mental states and Transitions into psycHosis (PAATH) study We aimed to identify the proportion of individuals at HR who make the transition into FEP and to elucidate the common characteristics that can help identify them. Sixty help-seeking HR individuals aged 16–35 years were stratified into those who met the criteria for HR/FEP (true positives) according to the Comprehensive Assessment of At-Risk Mental States (CAARMS) and those who did not (false positives). HR participants were followed up over 2 years using a comprehensive interview schedule. A random sample of 60 healthy volunteers (HVs) matched for age (16–35 years), sex and geographical area underwent the same battery of questionnaires. Only 5% of our HR sample transitioned to a structured clinical diagnosis of psychosis over 2 years. HR individuals had a higher prevalence of moderate or severe depression, anxiety and suicidality than HVs. In fact, psychometric analyses in other population samples indicate that psychotic experiences measure the severe end of a common mental distress factor, consistent with these results. HR individuals also experienced significantly more traumatic events than HVs, but equivalent distress. Almost half of HR individuals had at least one Schneiderian first-rank symptom traditionally considered indicative of schizophrenia and 21.6% had more than one. HR individuals had very poor global functioning and low quality of life. Conclusions This National Institute for Health Research programme developed our understanding of the social epidemiology of psychosis. A new theory-based intervention doubled the identification of HR and FEP in primary care and was cost-effective. The HR mental state has much in common with depression and anxiety; very few people transitioned to full psychosis over 2 years, in line with other recent evidence. This new understanding will help people at HR receive appropriate services focused on their current mental state. Funding The National Institute for Health Research Programme Grants for Applied Research programme.

Expert commentary

These studies are timely as NHSE embarks on a major programme to reinvigorate early intervention services. The innovative PsyMaptic resource enables commissioners to improve the precision with which specialist EISs can be planned according to local need, correcting previous underestimates of psychosis incidence while also accounting for local socio-demographic variation. Nor can early intervention services alone reduce treatment delay; bespoke GP education aligned with psychiatric liaison enhances detection of possible psychosis, demonstrates cost-effectiveness and challenges the woeful lack of such training. Moreover GPs can be reassured that those they refer at high risk merit active psychological intervention whether they ultimately develop psychosis or not.

Dr David Shiers, former GP and Honorary Reader in Early Psychosis, University of Manchester