HEART--the Hounslow Early Active Recovery Team: implementing an inclusive strength-based model of care for people with early psychosis

Early Intervention in Psychosis services: A systematic review and narrative synthesis of the barriers and facilitators to implementation

BACKGROUND

Early intervention in psychosis (EIP) services target the early manifestation of psychosis and provide multidisciplinary care. They demonstrate effectiveness and cost-effectiveness. Implementation of EIP services is inconsistent and piecemeal. This systematic review and narrative synthesis aims to identify barriers and facilitators to EIP service implementation.

METHODS

We conducted an electronic search of databases (EMBASE, Medline, Web of Science, and PsychINFO) to detect papers reporting EIP service implementation findings and associated barriers and facilitators. The search occurred between June to August 2020, and again in January 2021. Articles meeting inclusion criteria were extracted and narratively synthesized. A quality assessment was conducted using the Mixed Methods Appraisal Tool.

RESULTS

Twenty-three studies were selected. The most common study design was descriptive accounts of implementation. Patient age ranged varied from 14 to 35 years. We identified three barrier and facilitator domains: (a) system; (b) services; and (c) staff, and a range of subdomains. The most frequent subdomains were "funding" and "strength of collaboration and communication between EIP and outside groups and services". Associations between domains and subdomains were evident, particularly between systems and services.

CONCLUSIONS

A range of barriers and facilitators to EIP implementation exist. Some of these are generic factors germane across health systems and services, while others are specific to EIP services. A thorough prior understanding of these challenges and enablers are necessary before implementation is attempted. Accounting for these issues within local and national contexts may help predict and increase the likelihood of services' success, stability, and longevity.

Young adults' dynamic relationships with their families in early psychosis: Identifying relational strengths and supporting relational agency

OBJECTIVES

Most existing research on the family context of psychosis focuses on the 'burden' of caring for people experiencing psychosis. This research is the first to ask young people experiencing early psychosis to 'map' and describe their experiences and understandings of their family relationships, and how they have related to their psychosis and recovery.

DESIGN

The research took an inductive, multimodal hermeneutic-phenomenological approach (Boden, Larkin & Iyer, 2019, Qual. Res. Psychology, 16, 218-236; Boden & Larkin, 2020, A handbook of visual methods in psychology, 358-375).

METHOD

Ten young adults (18-23), under the care of early intervention in psychosis services in the UK, participated in an innovative relational mapping interview (Boden, Larkin & Iyer, 2018), which invited participants to draw a subjective 'map' of their important relationships. This visual methodology enables subtle, complex, ambivalent, and ambiguous aspects of the participants' experiences to be explored.

RESULTS

Findings explore the participants' accounts of how they love, protect, and care for their families; how they wrestle with family ties as they mature; and their feelings about talking about their mental health with loved ones, which was typically very difficult.

CONCLUSIONS

This paper advances understanding of recovery in psychosis through consideration of the importance of reciprocity, and the identification and nurturance of relational strengths. The capacity of a young person to withdraw or hold back when trying to protect others is understood as an example of relational agency. The possibility for extending strengths-based approaches and family work within the context of early intervention in psychosis services is discussed.

PRACTITIONER POINTS

Young adults experiencing early psychosis may benefit from support to identify their relational strengths and the opportunities they have for reciprocity within their family structures, where appropriate. Relational motivations may be important for a range of behaviours, including social withdrawal and non-communication. Services may benefit from exploring the young person's relational context and subjective meaning-making in regard to these actions. Young adults experiencing early psychosis may benefit from opportunities to make sense of their family dynamics and how this impacts on their recovery. Attachment-based and relationally oriented interventions that increase trust and openness, and reduce feelings of burdensomeness are likely to support family functioning as well as individual recovery.

Intervening Early with Family Members during First-Episode Psychosis: An Evaluation of Mental Health Nursing Psychoeducation within an Inpatient Unit

Provision of psychoeducation to families of service users experiencing a first-episode psychosis has been found to assist with relapse prevention and promoting recovery for service users. Psychoeducation also assists families to reduce isolation and gain relevant information and support. This study aimed to clarify the role inpatient staff can best have with families, targeted to the acute phase and early stage of the illness. Family members were provided an inpatient carer psychoeducation meeting and recruited for a feedback interview 6 months later. Findings suggest that family members require information provision and support during the admission, in addition to beneficial psychoeducation groups offered later in the community.

From the rhetoric to the real: A critical review of how the concepts of recovery and social inclusion may inform mental health nurse advanced level curricula - The eMenthe project

OBJECTIVES

This critical review addresses the question of how the concepts of recovery and social inclusion may inform mental health nurse education curricula at Master's level in order to bring about significant and positive change to practice.

DESIGN

This is a literature-based critical review incorporating a rapid review. It has been said that if done well, this approach can be highly relevant to health care studies and social interventions, and has substantial claims to be as rigorous and enlightening as other, more conventional approaches to literature (Rolfe, 2008).

DATA SOURCES

In this review, we have accessed contemporary literature directly related to the concepts of recovery and social inclusion in mental health.

REVIEW METHODS

We have firstly surveyed the international literature directly related to the concepts of recovery and social inclusion in mental health and used the concept of emotional intelligence to help consider educational outcomes in terms of the required knowledge, skills and attitudes needed to promote these values-based approaches in practice.

RESULTS

A number of themes have been identified that lend themselves to educational application. International frameworks exist that provide some basis for the developments of recovery and social inclusion approaches in mental health practice, however the review identifies specific areas for future development.

CONCLUSIONS

This is the first article that attempts to scope the knowledge, attitudes and skills required to deliver education for Master's level mental health nurses based upon the principles of recovery and social inclusion. Emotional intelligence theory may help to identify desired outcomes especially in terms of attitudinal development to promote the philosophy of recovery and social inclusive approaches in advanced practice. Whilst recovery is becoming enshrined in policy, there is a need in higher education to ensure that mental health nurse leaders are able to discern the difference between the rhetoric and the reality.

Employment and educational outcomes in early intervention programmes for early psychosis: a systematic review

AIMS

Young adults with early psychosis want to pursue normal roles - education and employment. This paper summarises the empirical literature on the effectiveness of early intervention programmes for employment and education outcomes.

METHODS

We conducted a systematic review of employment/education outcomes for early intervention programmes, distinguishing three programme types: (1) those providing supported employment, (2) those providing unspecified vocational services and (3) those without vocational services. We summarised findings for 28 studies.

RESULTS

Eleven studies evaluated early intervention programmes providing supported employment. In eight studies that reported employment outcomes separately from education outcomes, the employment rate during follow-up for supported employment patients was 49%, compared with 29% for patients receiving usual services. The two groups did not differ on enrolment in education. In four controlled studies, meta-analysis showed that the employment rate for supported employment participants was significantly higher than for control participants, odds ratio = 3.66 [1.93-6.93], p < 0.0001. Five studies (four descriptive and one quasi-experimental) of early intervention programmes evaluating unspecified vocational services were inconclusive. Twelve studies of early intervention programmes without vocational services were methodologically heterogeneous, using diverse methods for evaluating vocational/educational outcomes and precluding a satisfactory meta-analytic synthesis. Among studies with comparison groups, 7 of 11 (64%) reported significant vocational/education outcomes favouring early intervention over usual services.

CONCLUSIONS

In early intervention programmes, supported employment moderately increases employment rates but not rates of enrolment in education. These improvements are in addition to the modest effects early programmes alone have on vocational/educational outcomes compared with usual services.

Ten-Year Outcomes of First-Episode Psychoses in the MRC ÆSOP-10 Study

It has long been held that schizophrenia and other psychotic disorders have a predominately poor course and outcome. We have synthesized information on mortality, clinical and social outcomes from the ÆSOP-10 multicenter study, a 10-year follow-up of a large epidemiologically characterized cohort of 557 people with first-episode psychosis. Symptomatic remission and recovery were more common than previously believed. Distinguishing between symptom and social recovery is important given the disparity between these; even when symptomatic recovery occurs social inclusion may remain elusive. Multiple factors were associated with an increased risk of mortality, but unnatural death was reduced by 90% when there was full family involvement at first contact compared with those without family involvement. These results suggest that researchers, clinicians and those affected by psychosis should countenance a much more optimistic view of symptomatic outcome than was assumed when these conditions were first described.

Review of international early psychosis programmes and a model to overcome unique challenges to the treatment of early psychosis in the United States

AIM

This article presents a literature review of treatments for first-episode psychosis throughout the world and describes the POTENTIAL (Patient-Oriented Treatment for Early or New onset schizophrenia To Initiate A Long-term recovery) Early Psychosis Programme in detail, explaining the model and the rationale, as well as the uniqueness of the programme.

METHODS

An international search was conducted for English articles using PubMed, PsycINFO and PsycARTICLES, as well as the reference lists of published studies and reviews. One article that is currently in press was included, which was not part of the original literature search. Inclusion criteria included any published or in press study focused upon treatment programmes for early psychosis. Out of the 62 articles collected, 27 publications met this criterion and were utilized. In addition to identifying clinical programmes, gaps in treatment for this population were identified.

RESULTS

The primary method in the United States for the treatment of early psychosis is randomized trial for new pharmacological treatments where patients are research subjects. Although there are a multitude of both research and clinical programmes internationally, the few programmes that exist in the United States that focus upon first-episode psychosis are either research based or focus upon prodromal symptoms. Clinical programmes such as the POTENTIAL programme are nearly non-existent.

CONCLUSIONS

Although the POTENTIAL programme has been successful both clinically and financially, there are still more strides to be taken to improve upon young adult services. Future development of the programme is continuing with the incorporation of outcome data and outreach into the community.

The Singapore Early Psychosis Intervention Programme (EPIP): A programme evaluation

The alarmingly long duration of untreated psychosis (DUP) in Singapore and probable severe consequences were the impetus for establishing the Early Psychosis Intervention Programme (EPIP) in 2001. In 2007, EPIP became a part of the National Mental Health Blueprint. Here, we report some of the programme's outcomes.

METHOD

Consecutive patients accepted into EPIP from April 2007 to March 2011 were included. Programme inclusion criteria were: (1) age between 15 and 41 years, (2) first-episode psychotic disorder with no prior or minimal treatment, (3) no current history of substance abuse, and (4) no history of major medical or neurological illness. EPIP has incorporated an evaluation component to the clinical programme by administering regular structured assessments and generating operational statistics from our hospital's data systems.

RESULTS

Between April 2007 to March 2011, 815 patients had been accepted and 795 had baseline data. 50.8% (404/795) were males, with mean age of 27 years (±6.5 years). Mean DUP (SD) was 14.6 (±25.2) months and median was 6 months. At the end of two years, 71.1% (202/284) achieved symptomatic remission as defined by the Schizophrenia Working Group, 84.9% (241/284) scored 61 or more on Global Assessment of Functioning (GAF) disability and 76.5% (274/358) had returned back to school or were gainfully employed.

CONCLUSION

Being a national programme, EPIP had articulated process and outcome indicators to our stakeholders, and a periodic report card on these outcomes makes us accountable to our funders, our patients and their families.

The British research evidence for recovery, papers published between 2006 and 2009 (inclusive). Part One: a review of the peer-reviewed literature using a systematic approach

This paper is the first in a series of two which reviews the contemporary British evidence-base relating to recovery in mental health over a 4-year period. This review uses a systematic approach analysing the British peer-reviewed literature relating to recovery and mental health. The second paper in the series reviews the non-peer-reviewed literature. Recovery is not a new concept; however, it has recently become increasingly prevalent in practitioner, policy and research discourses. In total 12 papers met the inclusion criteria. Five main themes emerged from the analysis: hope and optimism, meaning to life, activities promoting recovery, definitions and discourses and implications for mental health practice. By including only peer-reviewed literature this paper is in a strong position to analyse the theoretical development of the recovery concept and highlight future directions for recovery in mental health services.

First episode psychosis and employment: a review

Despite considerable growth in treatments, interventions, services and research of young people with a first episode of psychosis, little attention has been given to the priorities of these young people, in particular, gaining employment. A literature review was undertaken with the aim of investigating: 1) whether young people with a first episode of psychosis want to work, 2) what challenges they experience regarding work, 3) what is understood about employment outcomes, 4) what the most effective interventions to enable them to gain employment may be, and 5) what the associated costs may be. The review found that these young people appear to want to work yet face a range of psychological and social challenges to achieving this. Typically by the time they first come into contact with mental health services a proportion are already falling out of education and employment, and this decline continues with contact with services. However, there are specific interventions that can support them to gain employment. The Individual Placement and Support approach, adapted to include support to fulfil educational goals, has demonstrated that a mean of 69% of young people with a first episode of psychosis can gain education and employment compared to 35% of controls.