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Dolar V, Chatterton ML, Le LKD, Mihalopoulos C, Thomas N, Engel L. Health Service Utilisation of People Living with Psychosis: Validity of Self-report Compared with Administrative Data in a Randomised Controlled Trial. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:255-264. [PMID: 37985649 DOI: 10.1007/s40258-023-00849-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Self-reported service use informs resource utilisation and cost estimates, though its validity for use within economic evaluations is uncertain. OBJECTIVE The aim of this study is to assess agreement in health resource-use measurement between self-reported and administrative data across different resource categories, over time and between different recall periods by subgroups among Australians living with psychosis. METHODS Data were obtained for 104 participants with psychotic disorders from a randomised controlled trial. Agreement between self-reported resource-use questionnaires and administrative data on community-based services and medication use was assessed through estimating differences of group mean number of visits and medications used and intraclass correlation coefficients (ICC) over multiple time periods. RESULTS ICC showed moderate agreement across most time periods for general practitioners, psychiatrists and mental health medications. No clear trends were discernible over time, between varying lengths of recall periods nor across participant subgroups. CONCLUSION Despite poor agreement, when measuring visits to psychologists and other health professionals, small overall differences in group mean number of visits indicate that self-reported data may still be valid for use in economic evaluations in people living with psychosis.
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Affiliation(s)
- Vergil Dolar
- Deakin Health Economics, School of Health and Social Development, Deakin University, Geelong, VIC, Australia
| | - Mary Lou Chatterton
- Deakin Health Economics, School of Health and Social Development, Deakin University, Geelong, VIC, Australia
- Monash University Health Economics Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Long Khanh-Dao Le
- Monash University Health Economics Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Cathrine Mihalopoulos
- Deakin Health Economics, School of Health and Social Development, Deakin University, Geelong, VIC, Australia
- Monash University Health Economics Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Neil Thomas
- Department of Psychological Sciences, School of Health Sciences, Centre for Mental Health, Swinburne University, Melbourne, Australia
| | - Lidia Engel
- Deakin Health Economics, School of Health and Social Development, Deakin University, Geelong, VIC, Australia.
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Behan C, Kennelly B, Roche E, Renwick L, Masterson S, Lyne J, O'Donoghue B, Waddington J, McDonough C, McCrone P, Clarke M. Early intervention in psychosis: health economic evaluation using the net benefit approach in a real-world setting. Br J Psychiatry 2020; 217:484-490. [PMID: 31339083 DOI: 10.1192/bjp.2019.126] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Early intervention in psychosis is a complex intervention, usually delivered in a specialist stand-alone setting, which aims to improve outcomes for people with psychosis. Previous studies have been criticised because the control used did not accurately reflect actual practice. AIMS To evaluate the cost-effectiveness of early intervention by estimating the incremental net benefit (INB) of an early-intervention programme, delivered in a real-world setting. INB measures the difference in monetary terms between alternative interventions. METHOD Two contemporaneous incidence-based cohorts presenting with first-episode psychosis, aged 18-65 years, were compared. Costs and outcomes were measured over 1 year. The main outcome was avoidance of a relapse that required admission to hospital or home-based treatment. RESULTS From the health sector perspective, the probability that early intervention was cost-effective was 0.77. The INB was €2465 per person (95% CI - €4418 to €9347) when society placed a value of €6000, the cost of an in-patient relapse, on preventing a relapse requiring admission or home care. Following adjustment, the probability that early intervention was cost-effective was 1, and the INB to the health sector was €3105 per person (95% CI -€8453 to €14 663). From a societal perspective, the adjusted probability that early intervention was cost-effective was 1, and the INB was €19 928 per person (95% CI - €2075 to €41 931). CONCLUSIONS Early intervention has a modest INB from the health sector perspective and a large INB from the societal perspective. The perspective chosen is critical when presenting results of an economic evaluation of a complex intervention.
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Affiliation(s)
- Caragh Behan
- Clinical Research Fellow, Dublin and East Treatment and Early Care Team (DETECT); and Clinical Research Fellow, School of Medicine, University College Dublin, Ireland
| | - Brendan Kennelly
- Lecturer and Programme Director (Health Economics MSc), Department of Economics, National University of Ireland Galway, Ireland
| | - Eric Roche
- Clinical Research Fellow, DETECT; and Clinical Research Fellow, School of Medicine, University College Dublin, Ireland
| | - Laoise Renwick
- Clinical Nurse Specialist, HRB Nursing and Midwifery Fellow, DETECT, Ireland
| | | | - John Lyne
- Consultant Psychiatrist, Beaumont Hospital, Dublin; and Honorary Senior Lecturer, Department of Psychiatry, Royal College of Surgeons in Ireland, Ireland
| | - Brian O'Donoghue
- Senior Research Fellow, Orygen National Centre of Excellence in Youth Mental Health; and Senior Research Fellow, University of Melbourne, Australia
| | - John Waddington
- Professor of Neuroscience, Faculty of Medicine and Health Sciences, Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Ireland
| | - Catherine McDonough
- Consultant Psychiatrist and Clinical Lead, COPE Early Intervention Service, Cavan and Monaghan Mental Health Services, Ireland
| | - Paul McCrone
- Professor of Health Economics, King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Mary Clarke
- Clinical Lead, DETECT; and Associate Clinical Professor of Psychiatry, Department of Psychiatry, School of Medicine, University College Dublin, Ireland
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Serretti A, Mandelli L, Bajo E, Cevenini N, Papili P, Mori E, Bigelli M, Berardi D. The socio-economical burden of schizophrenia: A simulation of cost-offset of early intervention program in Italy. Eur Psychiatry 2020; 24:11-6. [DOI: 10.1016/j.eurpsy.2008.07.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 07/25/2008] [Accepted: 07/26/2008] [Indexed: 11/28/2022] Open
Abstract
AbstractSchizophrenia is associated with a high familiar, social and economic burden. During the recent years early and specific intervention for first psychotic episodes has been suggested to improve the long term outcome of the disease. Despite the promising results obtained so far, early intervention is still scarcely applied. One major problem arises from the translation of research findings into stakeholder policies. In fact very few analyses of cost reductions obtained with early intervention have been reported. In the present paper we present a simulation of direct cost reduction that can be obtained with early intervention programmes. We based our analysis on available data about schizophrenia care costs in Italy and the expected cost reduction with the use of early intervention. We observed that the increase in costs due to the more intensive early intervention is largely compensated by the reduction of inpatient admissions with a reduction of direct costs of 6.01%. Despite the apparently small economic gain, early intervention offers more clinical and social benefits as it seems to be effective also in decreasing relapse rates, in improving the patients' quality of life and disability associated with psychosis and in increasing employment rates. Those indirect costs however are difficult to estimate and were not included in our model.In conclusion, our study supports the use of early intervention in schizophrenia, which could allow an outcome improvement with lower direct and indirect costs.
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Hunt GE, Siegfried N, Morley K, Brooke‐Sumner C, Cleary M. Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database Syst Rev 2019; 12:CD001088. [PMID: 31829430 PMCID: PMC6906736 DOI: 10.1002/14651858.cd001088.pub4] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Even low levels of substance misuse by people with a severe mental illness can have detrimental effects. OBJECTIVES To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care. SEARCH METHODS The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness. DATA COLLECTION AND ANALYSIS Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison. MAIN RESULTS Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence). AUTHORS' CONCLUSIONS We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.
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Affiliation(s)
- Glenn E Hunt
- The University of SydneyDiscipline of PsychiatryConcord Centre for Mental HealthHospital RoadSydneyNSWAustralia2139
| | - Nandi Siegfried
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitTybergCape TownSouth Africa
| | - Kirsten Morley
- The University of SydneyAddiction MedicineSydneyAustralia
| | - Carrie Brooke‐Sumner
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitTybergCape TownSouth Africa
| | - Michelle Cleary
- University of TasmaniaSchool of Nursing, College of Health and MedicineSydney, NSWAustralia
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Aceituno D, Vera N, Prina AM, McCrone P. Cost-effectiveness of early intervention in psychosis: systematic review. Br J Psychiatry 2019; 215:388-394. [PMID: 30696495 DOI: 10.1192/bjp.2018.298] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Early intervention in psychosis (EIP) has been developed as an approach to improve the prognosis of people with psychotic disorders and it has been claimed to be a more efficient model of care. However, the evidence is not definitive and doubts have spread regard to the economic outcomes of EIP services amid the usually restricted mental health budget.AimsWe aimed to review the cost-effectiveness evidence of EIP services worldwide. METHOD We systematically reviewed the economic literature about EIP following the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement guidelines. Studies were selected according to previously stated criteria and analysed with standardised critical appraisal tools for trial-based economic evaluations and modelling studies. RESULTS A total of 16 studies were selected after applying the eligibility criteria. Most of them were economic evaluations alongside clinical trials. The overall evidence was consistent in the cost-effectiveness of EIP compared with standard care for first episode of psychosis and the Clinical High Risk for Psychosis paradigm. Such evidence was replicated among different health systems, but mainly in high-income countries. The methodological quality of such evidence, however, was moderate and heterogeneity was significant across the studies. CONCLUSIONS There is consistent evidence that the implementation of EIP services might be a cost-effective alternative across different health systems. Such evidence, nevertheless, derives from heterogeneous and sometimes methodologically flawed studies, reducing the certainty of such statement. More efforts must be done to rigorously assess the value of this intervention, before expanding it among systems where mental health budgets are more constrained.Declaration of interestNone.
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Affiliation(s)
- David Aceituno
- PhD Candidate, Health Service and Population Research Department,Institute of Psychiatry,Psychology and Neuroscience, King's College London,UK; andPsychiatry Department, School of Medicine, Pontificia Universidad Católica de Chile,Chile
| | - Norha Vera
- PhD Candidate, Health Service and Population Research Department,Institute of Psychiatry, Psychology and Neuroscience,King's College London,UK
| | - A Matthew Prina
- Senior Lecturer in Epidemiology, Health Service and Population Research Department,Institute of Psychiatry, Psychology and Neuroscience,King's College London,UK
| | - Paul McCrone
- Professor of Health Economics, Health Service and Population Research Department,Institute of Psychiatry, Psychology and Neuroscience,King's College London,UK
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Wijnen BF, Thielen FW, Konings S, Feenstra T, Van Der Gaag M, Veling W, De Haan L, Ising H, Hiligsmann M, Evers SM, Smit F, Lokkerbol J. Designing and Testing of a Health-Economic Markov Model for Prevention and Treatment of Early Psychosis. Expert Rev Pharmacoecon Outcomes Res 2019; 20:269-279. [DOI: 10.1080/14737167.2019.1632194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Ben F.M. Wijnen
- Centre of Economic Evaluation (Trimbos Institute), Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Frederick W. Thielen
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Steef Konings
- Department of Psychiatry, University of Groningen,University Medical Center Groningen, Groningen, The Netherlands
| | - Talitha Feenstra
- Faculty of Medical Sciences, Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Mark Van Der Gaag
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands
- Department of Psychosis Research, Parnassia Psychiatric Institute, Den Haag, The Netherlands
| | - Wim Veling
- Department of Psychiatry, University of Groningen,University Medical Center Groningen, Groningen, The Netherlands
| | - Lieuwe De Haan
- Department of Psychiatry, Early Psychosis Section, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Helga Ising
- Department of Psychosis Research, Parnassia Psychiatric Institute, Den Haag, The Netherlands
| | - Mickaël Hiligsmann
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Silvia M.A.A. Evers
- Centre of Economic Evaluation (Trimbos Institute), Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Filip Smit
- Centre of Economic Evaluation (Trimbos Institute), Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Clinical Psychology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Joran Lokkerbol
- Centre of Economic Evaluation (Trimbos Institute), Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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Downs N, Alderman T, Bhakta S, Greenwood TA. Implementing a college mental health program - an overview of the first twelve months. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2019; 67:27-31. [PMID: 29601286 PMCID: PMC6336517 DOI: 10.1080/07448481.2018.1458032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/09/2018] [Accepted: 03/18/2018] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To evaluate the demographics and clinical utilization patterns among college students during the initial 12 months of a novel, multi-disciplinary, collaborative, college mental health program (CMHP). PARTICIPANTS Undergraduate and graduate students receiving treatment at the CMHP from Jan-Dec 2015. METHODS De-identified data was obtained via electronic health records for all students receiving care through the CMHP. RESULTS 1.2 FTE clinical providers treated 278 undergraduate and graduate students during the year (65.1% < age 26, 53.6% female, 49.6% caucasian). There were 1822 CMHP outpatient visits, 318 other medical visits and 103 total emergency room (ER)/inpatient visits. Ten students were identified as high utilizers of ER/inpatient services, while charges to the CMHP totaled $470,157 and total charges to the Health System were $2,378,315. CONCLUSIONS Students with complex psychiatric/medical co-morbidities received cost effective, convenient and integrative treatment. Over time, we hope to intervene earlier and decrease ER/inpatient visits.
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Affiliation(s)
- Nancy Downs
- a Psychiatry, University of California San Diego , La Jolla , San Diego , USA
| | - Tracy Alderman
- a Psychiatry, University of California San Diego , La Jolla , San Diego , USA
| | - Savita Bhakta
- a Psychiatry, University of California San Diego , La Jolla , San Diego , USA
| | - Tiffany A Greenwood
- a Psychiatry, University of California San Diego , La Jolla , San Diego , USA
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Hetrick SE, O'Connor DA, Stavely H, Hughes F, Pennell K, Killackey E, McGorry PD. Development of an implementation guide to facilitate the roll-out of early intervention services for psychosis. Early Interv Psychiatry 2018; 12:1100-1111. [PMID: 28177191 DOI: 10.1111/eip.12420] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/06/2016] [Accepted: 11/11/2016] [Indexed: 11/29/2022]
Abstract
AIM Our aim was to develop an implementation guide that was informed by an analysis of context-specific barriers and enablers, behaviour change theory, as well as evidence about the effects of implementation interventions, for the establishment and scaling up of an early intervention model for psychosis (called Early Psychosis Prevention and Intervention Centre (EPPIC)). METHODS We used a systematic approach involving four steps. First, the target behaviours of the EPPIC model for implementation were specified. Second, a consultation was undertaken to explore the barriers and enablers to undertaking these priority minimum standard clinical behaviours. Third, an implementation strategy that included a range of behaviour change techniques tailored to address the identified barriers was developed. Finally, a tool to assess whether those implementing the EPPIC model maintained fidelity to the implementation strategy was designed. RESULTS We identified a range of barriers that could act to dilute the core components of the EPPIC model and compromise its implementation. An implementation strategy using theory and evidence-based strategies for behaviour change was designed to address these barriers. CONCLUSIONS The process we used in the development of the implementation strategy provided a unique opportunity to consider the essential areas to cover, how to make information easily understandable and accessible while noting the complexity of issues involved in not only implementation, but also the scaling up of the EPPIC model for services.
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Affiliation(s)
- Sarah E Hetrick
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre of Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Denise A O'Connor
- Implementation Consultant, School of Public Health and Preventive Medicine at Monash University, Melbourne, Australia
| | - Heather Stavely
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
| | - Frank Hughes
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
| | - Kerryn Pennell
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre of Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Eoin Killackey
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre of Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Patrick D McGorry
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre of Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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Radhakrishnan M, McCrone P, Lafortune L, Everard L, Fowler D, Amos T, Freemantle N, Singh SP, Marshall M, Sharma V, Lavis A, Jones PB, Birchwood M. Cost-effectiveness of early intervention services for psychosis and fidelity to national policy implementation guidance. Early Interv Psychiatry 2018; 12:747-756. [PMID: 28857431 DOI: 10.1111/eip.12481] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/26/2017] [Accepted: 07/11/2017] [Indexed: 11/28/2022]
Abstract
AIM Early intervention services (EIS) for psychosis are being implemented, internationally. It is important to learn from established examples and define the components and intensity of services that provide good value for money. This study aims to assess the cost-effectiveness of EIS according to how closely they adhered to the recommendations of the English Department of Health 2001 Policy Implementation Guide (PIG). METHODS EIS from the National Eden Study were assessed using a measure of fidelity to the PIG that rated the presence or absence of 64 recommended items relating to team structure and practice. EIS were then classified into three groups: those with fidelity of 75-80%, 81-90% and 91-95%. Patient-level resource use and outcomes were measured 1 year following inception into the service; costs were calculated and combined with quality-adjusted life years (QALYs) gained. RESULTS At a threshold of £20 000 per QALY, the 81-90% fidelity group had a 56.3% likelihood of being the most cost-effective option followed by 75-80% fidelity at 35.8% and 91-95% fidelity group (7.9%). CONCLUSIONS The results from England suggest that striving to maximize fidelity may not be warranted, but that dropping below a certain level of fidelity may result in inefficient use of resources.
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Affiliation(s)
| | - Paul McCrone
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College, London, UK
| | - Louise Lafortune
- Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Linda Everard
- The Early Intervention Service, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - David Fowler
- Department of Psychology, University of Sussex, Sussex, UK
| | - Tim Amos
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK
| | - Nick Freemantle
- Department of Primary Care and Population Health, University College London, London, UK
| | - Swaran P Singh
- Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Max Marshall
- School of Medicine, University of Manchester, Manchester, UK
| | - Vimal Sharma
- Early Intervention Service, Cheshire and Wirral NHS Foundation Trust & University of Chester, UK
| | - Anna Lavis
- Institute of Applied Health Research, University of Birmingham, UK
| | - Peter B Jones
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Max Birchwood
- School of Medicine, University of Manchester, Manchester, UK
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El-Adl M, Burke J, Little K. First-episode psychosis: primary care experience and implications for service development. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.bp.108.019646] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aim and MethodsTo capture the local primary care experience of first-episode psychosis before developing a local early intervention in psychosis service. A survey of Northamptonshire general practitioners (GPs) using a confidential questionnaire was carried out.ResultsOut of 284 GPs, 123 (43%) responded. General practitioners are unlikely to start treatment before referring to a specialist service: 63 GPs (51% of responders) start treatment in 10% or less of individuals with first-episode psychosis and 19 (15.5%) GPs start treatment in 75% or more before referring them to psychiatric service; 42 GPs (34%) refer those who request/accept a referral and 66 GPs (53%) refer all even if they refuse. Overall, 92 GPs (74%) agreed that an early intervention in psychosis service is needed and 77 (63%) GPs welcome having a mental health clinic in their surgery.Clinical ImplicationsIndividuals are more likely to accept referral to a psychiatric service if offered than to ask for it. People disengaging, stigma, the service being difficult to access/inappropriate and carers' lack of knowledge about mental illness are the likely causes for delayed referral.
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Abstract
By focusing therapeutic effort on the early stages of psychotic disorders, effective early intervention should improve short- and long-term outcomes. Strategies include pre-psychotic and prodromal interventions to prevent emergence of psychosis, detecting untreated cases in the community and facilitating recovery in established cases of psychosis. The evidence base for each of these strategies is currently limited, although several international trials are under way. The Department of Health in the UK has announced the intention of setting up 50 early intervention services nationally, several of which are already operational. In this article, we briefly discuss the differing ways in which early intervention is conceptualised, summarise the evidence supporting it in established cases of psychosis, suggest appropriate service models and describe two early intervention services in south-west London.
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Hamilton MP, Hetrick SE, Mihalopoulos C, Baker D, Browne V, Chanen AM, Pennell K, Purcell R, Stavely H, McGorry PD. Identifying attributes of care that may improve cost‐effectiveness in the youth mental health service system. Med J Aust 2017; 207:S27-S37. [DOI: 10.5694/mja17.00972] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/17/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Matthew P Hamilton
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
| | - Sarah E Hetrick
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
- Centre of Youth Mental Health, University of Melbourne, Melbourne, VIC
| | | | - David Baker
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
| | - Vivienne Browne
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
- Centre of Youth Mental Health, University of Melbourne, Melbourne, VIC
| | - Andrew M Chanen
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
- Centre of Youth Mental Health, University of Melbourne, Melbourne, VIC
| | - Kerryn Pennell
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
| | - Rosemary Purcell
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
- Centre of Youth Mental Health, University of Melbourne, Melbourne, VIC
| | - Heather Stavely
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
| | - Patrick D McGorry
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC
- Centre of Youth Mental Health, University of Melbourne, Melbourne, VIC
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13
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Oppetit A, Brébant C, Monchablon D, Bourgin J, Gaillard R, Olié JP, Krebs MO, Morvan Y. [Early detection of mental health disorders at school: The Fil Harmonie pilot program]. Encephale 2017; 44:232-238. [PMID: 28347523 DOI: 10.1016/j.encep.2017.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 01/17/2017] [Accepted: 01/21/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Most psychiatric disorders arise during adolescence, a period of life during which school takes an important place. School in France has an official mission of health education and prevention, and early detection of mental disorders is part of these goals. The aim of this study is to describe an innovative service operating in Paris that helps educational staff to deal with students having psychological or psychiatric symptoms. The Fil Harmonie program was launched in 2011. It consists of a telephone line available to all educational staff working for high schools in Paris. METHODS When in need of assistance, a member of the educational staff can call the dedicated hotline and expose the situation of their student to a trained psychologist. Over the course of the study, data concerning these phone calls were collected such as: socio-demographic characteristics of the student, the reason behind the call, the caller's professional role within the school, and care pathway information. All data collected during the phone calls were anonymized and computerized. We performed an observational descriptive study based on this data by using mixed methods: we integrated quantitative analysis and qualitative research in order to provide a better understanding of the Fil Harmonie program. RESULTS Between 18 September 2013 and 12 May 2014, the Fil Harmonie program handled 68 calls from educational staff. Students concerned by the calls were aged between 11 and 22 and the average age was 17.3 years. Over half (52.5%) of the pupils concerned had never seen a mental health professional before the call. In more than 70% of cases, the caller was a school nurse while other professionals such as teachers or headmasters represented only a minority of the callers. Approximately two thirds (67.2%) of students were described by the caller as socially isolated and 48.2% were described as sad or anhedonic. One out of four (26.7%) had repeated a school year at least once, and 55.9% of young people for whom a member of staff contacted Fil Harmonie had been missing class. In 56.7% of cases, there had been no contact with the student's family about the psychological situation. The qualitative analysis particularly highlighted the complexity of the collaboration between the family and the educational staff. CONCLUSION Schooling is an important opportunity to seize in mental health regarding early detection and access to care. By fostering collaboration between educational professionals and mental health services, Fil Harmonie meets a public health objective of prevention and should contribute to the reduction of care delays thus leading to better treatment outcome. Our study shows that such programs are feasible and answer a real need in our current health care system.
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Affiliation(s)
- A Oppetit
- Service hospitalo-universitaire, faculté de médecine Paris Descartes, hôpital Sainte-Anne, université Paris Descartes, 1, rue Cabanis, 75014 Paris, France; Inserm U894, laboratoire physiopathologie des maladies psychiatriques, centre psychiatrie et neuroscience, université Paris Descartes, 2ter, rue d'Alésia, 75014 Paris, France
| | - C Brébant
- Relais étudiant lycéen, fondation santé des étudiants de France, 60, rue des Grands-Moulins, 75013 Paris, France
| | - D Monchablon
- Relais étudiant lycéen, fondation santé des étudiants de France, 60, rue des Grands-Moulins, 75013 Paris, France
| | - J Bourgin
- Service hospitalo-universitaire, faculté de médecine Paris Descartes, hôpital Sainte-Anne, université Paris Descartes, 1, rue Cabanis, 75014 Paris, France; Inserm U894, laboratoire physiopathologie des maladies psychiatriques, centre psychiatrie et neuroscience, université Paris Descartes, 2ter, rue d'Alésia, 75014 Paris, France
| | - R Gaillard
- Service hospitalo-universitaire, faculté de médecine Paris Descartes, hôpital Sainte-Anne, université Paris Descartes, 1, rue Cabanis, 75014 Paris, France; Inserm U894, laboratoire physiopathologie des maladies psychiatriques, centre psychiatrie et neuroscience, université Paris Descartes, 2ter, rue d'Alésia, 75014 Paris, France
| | - J-P Olié
- Service hospitalo-universitaire, faculté de médecine Paris Descartes, hôpital Sainte-Anne, université Paris Descartes, 1, rue Cabanis, 75014 Paris, France; Inserm U894, laboratoire physiopathologie des maladies psychiatriques, centre psychiatrie et neuroscience, université Paris Descartes, 2ter, rue d'Alésia, 75014 Paris, France
| | - M-O Krebs
- Service hospitalo-universitaire, faculté de médecine Paris Descartes, hôpital Sainte-Anne, université Paris Descartes, 1, rue Cabanis, 75014 Paris, France; Inserm U894, laboratoire physiopathologie des maladies psychiatriques, centre psychiatrie et neuroscience, université Paris Descartes, 2ter, rue d'Alésia, 75014 Paris, France
| | - Y Morvan
- Inserm U894, laboratoire physiopathologie des maladies psychiatriques, centre psychiatrie et neuroscience, université Paris Descartes, 2ter, rue d'Alésia, 75014 Paris, France; Département de psychologie, UFR SPSE, laboratoire CLIPSYD, université Paris Nanterre, 200, avenue de la République, 92000 Nanterre, France.
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Behan C, Masterson S, Clarke M. Systematic review of the evidence for service models delivering early intervention in psychosis outside the stand-alone centre. Early Interv Psychiatry 2017; 11:3-13. [PMID: 27061731 DOI: 10.1111/eip.12334] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 02/07/2016] [Accepted: 02/18/2016] [Indexed: 11/28/2022]
Abstract
AIM Although early intervention in psychosis is an accepted policy internationally, the evidence base for this paradigm, originates mostly from the specialist model. In a real world setting, variations of this model are often implemented. The aim of this paper is to systematically evaluate the evidence for delivering early intervention outside the specialist stand-alone centre. METHODS A systematic search following the PRISMA guidelines was undertaken in Medline, PsycInfo, Embase and the Cochrane trials register. The search was limited to articles in English from 1990 to end of January 2016. Inclusion criteria for the review comprised comparative evaluations of services delivering early intervention in psychosis outside the specialist model. Exclusion criteria included prodromal services, descriptions of services without reference to a comparator and stand-alone specialist services evaluated in comparison to treatment as usual. RESULTS There were 637 unique citations. Twenty-eight papers were reviewed at second-stage screening. The majority were excluded as they compared specialist early intervention with treatment as usual, did not evaluate the first episode or had no comparator. Seven peer-reviewed publications and two conference papers fulfilled criteria evaluating models of delivering early intervention other than the specialist model. CONCLUSIONS There is a spaucity of evidence evaluating models other than specialist models in early intervention. Published studies are heterogeneous in design and outcome. Although there have been two recent trials evaluating integrated early intervention in comparison with treatment as usual, it remains unclear whether reported improved outcomes of specialist centres apply to other models.
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Affiliation(s)
- Caragh Behan
- DETECT Early Intervention in Psychosis Service, Dublin, Ireland
| | - Sarah Masterson
- DETECT Early Intervention in Psychosis Service, Dublin, Ireland
| | - Mary Clarke
- DETECT Early Intervention in Psychosis Service, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
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15
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Roberts E, Cumming J, Nelson K. A Review of Economic Evaluations of Community Mental Health Care. Med Care Res Rev 2016; 62:503-43. [PMID: 16177456 DOI: 10.1177/1077558705279307] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The authors review the methodology and findings of economic evaluations of 42 community mental health care programs reported in the English-language literature between 1979 and 2003. There were three substantial methodological problems in the literature: costs were often not completely specified, the quality of econometric analysis was often low, and most evaluations failed to integrate cost and health outcome information. Well-conducted research shows that care in the community dominates hospital in-patient care, achieving better outcomes at lower or equal cost. It is less clear what types of community programs are most cost-effective. Future research should focus on identifying which types of community care are most cost effective and at what level of intensity they are most effective.
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16
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Rosenheck R, Leslie D, Sint K, Lin H, Robinson DG, Schooler NR, Mueser KT, Penn DL, Addington J, Brunette MF, Correll CU, Estroff SE, Marcy P, Robinson J, Severe J, Rupp A, Schoenbaum M, Kane JM. Cost-Effectiveness of Comprehensive, Integrated Care for First Episode Psychosis in the NIMH RAISE Early Treatment Program. Schizophr Bull 2016; 42:896-906. [PMID: 26834024 PMCID: PMC4903057 DOI: 10.1093/schbul/sbv224] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
This study compares the cost-effectiveness of Navigate (NAV), a comprehensive, multidisciplinary, team-based treatment approach for first episode psychosis (FEP) and usual Community Care (CC) in a cluster randomization trial. Patients at 34 community treatment clinics were randomly assigned to either NAV (N = 223) or CC (N = 181) for 2 years. Effectiveness was measured as a one standard deviation change on the Quality of Life Scale (QLS-SD). Incremental cost effectiveness ratios were evaluated with bootstrap distributions. The Net Health Benefits Approach was used to evaluate the probability that the value of NAV benefits exceeded its costs relative to CC from the perspective of the health care system. The NAV group improved significantly more on the QLS and had higher outpatient mental health and antipsychotic medication costs. The incremental cost-effectiveness ratio was $12 081/QLS-SD, with a .94 probability that NAV was more cost-effective than CC at $40 000/QLS-SD. When converted to monetized Quality Adjusted Life Years, NAV benefits exceeded costs, especially at future generic drug prices.
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Affiliation(s)
- Robert Rosenheck
- Department of Psychiatry and Public Health, Yale Medical School, New Haven, CT;
| | - Douglas Leslie
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Kyaw Sint
- Department of Psychiatry and Public Health, Yale Medical School, New Haven, CT
| | - Haiqun Lin
- Department of Psychiatry and Public Health, Yale Medical School, New Haven, CT
| | | | - Nina R Schooler
- Psychiatry Research, Zucker Hillside Hospital, North Shore-Long Island Jewish, Glen Oaks, NY; Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY; Department of Psychiatry, SUNY Downstate Medical Center, Brooklyn, NY
| | - Kim T Mueser
- Center for Psychiatric Rehabilitation, Departments of Occupational Therapy, Psychiatry, and Psychology, Boston University, Boston, MA
| | - David L Penn
- Department of Psychology, University of North Carolina-Chapel Hill, Chapel Hill, NC; School of Psychology, Australian Catholic University, Melbourne, Australia
| | - Jean Addington
- Hotchkiss Brain Institute, Department of Psychiatry, University of Calgary, Calgary, Canada
| | - Mary F Brunette
- Geisel School of Medicine at Dartmouth, Lebanon, NH; Bureau of Behavioral Health, DHHS, Concord, NH
| | | | - Sue E Estroff
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC
| | - Patricia Marcy
- Psychiatry Research, Zucker Hillside Hospital, North Shore-Long Island Jewish, Glen Oaks, NY
| | | | | | - Agnes Rupp
- National Institute of Mental Health, Rockville, MD
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17
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Park AL, McCrone P, Knapp M. Early intervention for first-episode psychosis: broadening the scope of economic estimates. Early Interv Psychiatry 2016; 10:144-51. [PMID: 24739331 DOI: 10.1111/eip.12149] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 03/11/2014] [Indexed: 01/29/2023]
Abstract
AIM To explore the economic impacts of early intervention in England on outcomes and costs for people with first-episode psychosis. METHODS Three decision analytical models were constructed to compare treatment by early intervention for first-episode psychosis with standard care in relation to employment, education, homicide and suicide. Data on effectiveness and costs were taken from previous studies and expert opinion. Sensitivity analyses tested the robustness of assumptions. RESULTS Our models indicate that early intervention demonstrates savings of £2087 per person over 3 years from improved employment and education outcomes. In addition, the annual costs over 10 years related to homicide after early intervention were £80 lower than for standard care. There were also annual savings of £957 per person for early intervention over 4 years compared to standard care as a result of suicides averted. CONCLUSIONS Not only can investment in early intervention help reduce some of the long-term costs and consequences of mental disorders to the health-care system. In addition, there are broader economic benefits that strengthen the potential cost savings to society.
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Affiliation(s)
- A-La Park
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Paul McCrone
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, King's College London, London, UK
| | - Martin Knapp
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK.,Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, King's College London, London, UK
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18
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Breitborde NJK, Bell EK, Dawley D, Woolverton C, Ceaser A, Waters AC, Dawson SC, Bismark AW, Polsinelli AJ, Bartolomeo L, Simmons J, Bernstein B, Harrison-Monroe P. The Early Psychosis Intervention Center (EPICENTER): development and six-month outcomes of an American first-episode psychosis clinical service. BMC Psychiatry 2015; 15:266. [PMID: 26511605 PMCID: PMC4625429 DOI: 10.1186/s12888-015-0650-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 10/14/2015] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND There is growing evidence that specialized clinical services targeted toward individuals early in the course of a psychotic illness may be effective in reducing both the clinical and economic burden associated with these illnesses. Unfortunately, the United States has lagged behind other countries in the delivery of specialized, multi-component care to individuals early in the course of a psychotic illness. A key factor contributing to this lag is the limited available data demonstrating the clinical benefits and cost-effectiveness of early intervention for psychosis among individuals served by the American mental health system. Thus, the goal of this study is to present clinical and cost outcome data with regard to a first-episode psychosis treatment center within the American mental health system: the Early Psychosis Intervention Center (EPICENTER). METHODS Sixty-eight consecutively enrolled individuals with first-episode psychosis completed assessments of symptomatology, social functioning, educational/vocational functioning, cognitive functioning, substance use, and service utilization upon enrollment in EPICENTER and after 6 months of EPICENTER care. All participants were provided with access to a multi-component treatment package comprised of cognitive behavioral therapy, family psychoeducation, and metacognitive remediation. RESULTS Over the first 6 months of EPICENTER care, participants experienced improvements in symptomatology, social functioning, educational/vocational functioning, cognitive functioning, and substance abuse. The average cost of care during the first 6 months of EPICENTER participation was lower than the average cost during the 6-months prior to joining EPICENTER. These savings occurred despite the additional costs associated with the receipt of EPICENTER care and were driven primarily by reductions in the utilization of inpatient psychiatric services and contacts with the legal system. CONCLUSIONS The results of our study suggest that multi-component interventions for first-episode psychosis provided in the US mental health system may be both clinically-beneficial and cost-effective. Although additional research is needed, these findings provide preliminary support for the growing delivery of specialized multi-component interventions for first-episode psychosis within the United States. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01570972; Date of Trial Registration: November 7, 2011.
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Affiliation(s)
- Nicholas J. K. Breitborde
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, Ohio USA ,Department of Psychiatry, The University of Arizona, Tucson, Arizona USA
| | - Emily K. Bell
- Department of Psychiatry, The University of Arizona, Tucson, Arizona USA
| | - David Dawley
- Department of Psychiatry, The University of Arizona, Tucson, Arizona, USA.
| | - Cindy Woolverton
- Department of Psychology, The University of Arizona, Tucson, Arizona, USA.
| | - Alan Ceaser
- Department of Psychiatry, The University of Arizona, Tucson, Arizona, USA. .,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA.
| | - Allison C. Waters
- Department of Psychiatry, The University of Arizona, Tucson, Arizona USA ,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia USA
| | - Spencer C. Dawson
- Department of Psychology, The University of Arizona, Tucson, Arizona USA
| | - Andrew W. Bismark
- VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, California USA
| | | | - Lisa Bartolomeo
- Department of Psychiatry, The University of Arizona, Tucson, Arizona, USA.
| | - Jessica Simmons
- Department of Education, The University of Arizona, Tucson, Arizona, USA.
| | - Beth Bernstein
- Department of Psychiatry, The University of Arizona, Tucson, Arizona, USA.
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19
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Parcover J, Mays S, McCarthy A. Implementing a Public Health Approach to Addressing Mental Health Needs in a University Setting: Lessons and Challenges. JOURNAL OF COLLEGE STUDENT PSYCHOTHERAPY 2015. [DOI: 10.1080/87568225.2015.1045781] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Development and evaluation of an educational intervention in youth mental health for primary care practitioners. Ir J Psychol Med 2014; 32:137-146. [PMID: 30185272 DOI: 10.1017/ipm.2014.71] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Irish adolescents have one of the highest rates of suicide and self-harm in the European Union. Although primary care has been identified as an opportune environment in which to detect and treat mental health problems in adolescents, lack of training among primary care professionals (PCPs) is a barrier to optimum identification and treatment. We describe the development and evaluation of an educational intervention on youth mental health and substance misuse for PCPs. METHODS Thirty general practitioners and other PCPs working in the Mid-West region participated in an educational session on youth-friendly consultations, and identification and treatment of mental ill-health and substance use. Learning objectives were addressed through a presentation, video demonstration, small group discussions, role play, question-and-answer sessions with clinical experts, and an information pack. Following the session, participants completed an evaluation form assessing knowledge gain and usefulness of different components of the session. RESULTS A total of 71% of participants were involved in the provision of care to young people and 55% had no previous training in youth mental health or substance abuse. Participants rated knowledge gains as highest with regard to understanding the importance of early intervention, and primary care, in youth mental health. The components rated as most useful were case studies/small group discussion, the 'question-and-answer session' with clinical experts, and peer interaction. CONCLUSIONS The educational session outlined in this pilot was feasible and acceptable and may represent an effective way to train professionals to help tackle the current crisis in youth mental health.
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Hunt GE, Siegfried N, Morley K, Sitharthan T, Cleary M. Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database Syst Rev 2013:CD001088. [PMID: 24092525 DOI: 10.1002/14651858.cd001088.pub3] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Even low levels of substance misuse by people with a severe mental illness can have detrimental effects. OBJECTIVES To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care. SEARCH METHODS For this update (2013), the Trials Search Co-ordinator of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (July 2012), which is based on regular searches of major medical and scientific databases. The principal authors conducted two further searches (8 October 2012 and 15 January 2013) of the Cochrane Database of Systematic Reviews, MEDLINE and PsycINFO. A separate search for trials of contingency management was completed as this was an additional intervention category for this update. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness. DATA COLLECTION AND ANALYSIS We independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of relative risk (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. For all meta-analyses we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison. MAIN RESULTS We included 32 trials with a total of 3165 participants. Evaluation of long-term integrated care included four RCTs (n = 735). We found no significant differences on loss to treatment (n = 603, 3 RCTs, RR 1.09 CI 0.82 to 1.45, low quality of evidence), death by 3 years (n = 421, 2 RCTs, RR 1.18 CI 0.39 to 3.57, low quality of evidence), alcohol use (not in remission at 36 months) (n = 143, 1 RCT, RR 1.15 CI 0.84 to 1.56,low quality of evidence), substance use (n = 85, 1 RCT, RR 0.89 CI 0.63 to 1.25, low quality of evidence), global assessment of functioning (n = 171, 1 RCT, MD 0.7 CI 2.07 to 3.47, low quality of evidence), or general life satisfaction (n = 372, 2 RCTs, MD 0.02 higher CI 0.28 to 0.32, moderate quality of evidence).For evaluation of non-integrated intensive case management with usual treatment (4 RCTs, n = 163) we found no statistically significant difference for loss to treatment at 12 months (n = 134, 3 RCTs, RR 1.21 CI 0.73 to 1.99, very low quality of evidence).Motivational interviewing plus cognitive behavioural therapy compared to usual treatment (7 RCTs, total n = 878) did not reveal any advantage for retaining participants at 12 months (n = 327, 1 RCT, RR 0.99 CI 0.62 to 1.59, low quality of evidence) or for death (n = 493, 3 RCTs, RR 0.72 CI 0.22 to 2.41, low quality of evidence), and no benefit for reducing substance use (n = 119, 1 RCT, MD 0.19 CI -0.22 to 0.6, low quality of evidence), relapse (n = 36, 1 RCT, RR 0.5 CI 0.24 to 1.04, very low quality of evidence) or global functioning (n = 445, 4 RCTs, MD 1.24 CI 1.86 to 4.34, very low quality of evidence).Cognitive behavioural therapy alone compared with usual treatment (2 RCTs, n = 152) showed no significant difference for losses from treatment at 3 months (n = 152, 2 RCTs, RR 1.12 CI 0.44 to 2.86, low quality of evidence). No benefits were observed on measures of lessening cannabis use at 6 months (n = 47, 1 RCT, RR 1.30 CI 0.79 to 2.15, very low quality of evidence) or mental state (n = 105, 1 RCT, Brief Psychiatric Rating Scale MD 0.52 CI -0.78 to 1.82, low quality of evidence).We found no advantage for motivational interviewing alone compared with usual treatment (8 RCTs, n = 509) in reducing losses to treatment at 6 months (n = 62, 1 RCT, RR 1.71 CI 0.63 to 4.64, very low quality of evidence), although significantly more participants in the motivational interviewing group reported for their first aftercare appointment (n = 93, 1 RCT, RR 0.69 CI 0.53 to 0.9). Some differences, favouring treatment, were observed in abstaining from alcohol (n = 28, 1 RCT, RR 0.36 CI 0.17 to 0.75, very low quality of evidence) but not other substances (n = 89, 1 RCT, RR -0.07 CI -0.56 to 0.42, very low quality of evidence), and no differences were observed in mental state (n = 30, 1 RCT, MD 0.19 CI -0.59 to 0.21, very low quality of evidence).We found no significant differences for skills training in the numbers lost to treatment by 12 months (n = 94, 2 RCTs, RR 0.70 CI 0.44 to 1.1, very low quality of evidence).We found no differences for contingency management compared with usual treatment (2 RCTs, n = 206) in numbers lost to treatment at 3 months (n = 176, 1 RCT, RR 1.65 CI 1.18 to 2.31, low quality of evidence), number of stimulant positive urine tests at 6 months (n = 176, 1 RCT, RR 0.83 CI 0.65 to 1.06, low quality of evidence) or hospitalisations (n = 176, 1 RCT, RR 0.21 CI 0.05 to 0.93, low quality of evidence).We were unable to summarise all findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low or very low due to high or unclear risks of bias because of poor trial methods, or poorly reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. AUTHORS' CONCLUSIONS We included 32 RCTs and found no compelling evidence to support any one psychosocial treatment over another for people to remain in treatment or to reduce substance use or improve mental state in people with serious mental illnesses. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high quality trials are required which address these concerns and improve the evidence in this important area.
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Affiliation(s)
- Glenn E Hunt
- Discipline of Psychiatry, The University of Sydney, Concord Centre for Mental Health, Hospital Road, Sydney, NSW, Australia, 2139
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McGorry P, Mihalopoulos C. Unhealthy scepticism: time for a fair go for best available evidence. Aust N Z J Psychiatry 2013; 47:602-4. [PMID: 23814150 DOI: 10.1177/0004867413491163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Patrick McGorry
- Orygen Youth Health Research Centre and Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia.
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23
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Affiliation(s)
- Melissa Raven
- Public Health, Flinders University, Adelaide, Australia.
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24
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Prevention and recovery in early psychosis (PREP(®)): building a public-academic partnership program in Massachusetts, United States. Asian J Psychiatr 2013; 6:171-7. [PMID: 23466116 DOI: 10.1016/j.ajp.2012.10.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 10/22/2012] [Accepted: 10/25/2012] [Indexed: 12/22/2022]
Abstract
Recently, there has been increasing emphasis on early intervention (EI) for psychotic disorders. EI programs in public mental health settings have been established in countries such as Australia, the United Kingdom, and Canada. However, there are relatively few EI programs in the United States (U.S.). Here we describe the conceptual origins and practical development of the PREP program, i.e., Prevention and Recovery in Early Psychosis, as it evolved in a public academic psychiatry setting in Boston, Massachusetts, U.S. PREP developed over a decade through a partnership between the Massachusetts Department of Mental Health and academic institutions within the Harvard Department of Psychiatry. We discuss the evolution, programmatic features, funding mechanisms, staffing, and the role of clinical training in PREP. The key principles in developing the PREP Program include the focus on early, evidence based, person-centered and phase-specific, integrated and continuous, comprehensive care. This program has served as a foundation for the emergence of related services at our institution, including a research clinic treating those at clinical high risk or within the putative "prodromal" period preceding frank psychosis. This account offers one possible blueprint for the development of EI programs despite the lack in the U.S. of a national mandate for EI or prevention-based mental health programs.
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Hastrup LH, Kronborg C, Bertelsen M, Jeppesen P, Jorgensen P, Petersen L, Thorup A, Simonsen E, Nordentoft M. Cost-effectiveness of early intervention in first-episode psychosis: economic evaluation of a randomised controlled trial (the OPUS study). Br J Psychiatry 2013; 202:35-41. [PMID: 23174515 DOI: 10.1192/bjp.bp.112.112300] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Information about the cost-effectiveness of early intervention programmes for first-episode psychosis is limited. AIMS To evaluate the cost-effectiveness of an intensive early-intervention programme (called OPUS) (trial registration NCT00157313) consisting of enriched assertive community treatment, psychoeducational family treatment and social skills training for individuals with first-episode psychosis compared with standard treatment. METHOD An incremental cost-effectiveness analysis of a randomised controlled trial, adopting a public sector perspective was undertaken. RESULTS The mean total costs of OPUS over 5 years (€123,683, s.e. = 8970) were not significantly different from that of standard treatment (€148,751, s.e. = 13073). At 2-year follow-up the mean Global Assessment of Functioning (GAF) score in the OPUS group (55.16, s.d. = 15.15) was significantly higher than in standard treatment group (51.13, s.d. = 15.92). However, the mean GAF did not differ significantly between the groups at 5-year follow-up (55.35 (s.d. = 18.28) and 54.16 (s.d. = 18.41), respectively). Cost-effectiveness planes based on non-parametric bootstrapping showed that OPUS was less costly and more effective in 70% of the replications. For a willingness-to-pay up to €50,000 the probability that OPUS was cost-effective was more than 80%. CONCLUSIONS The incremental cost-effectiveness analysis showed that there was a high probability of OPUS being cost-effective compared with standard treatment.
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Fusar-Poli P, Borgwardt S, Bechdolf A, Addington J, Riecher-Rössler A, Schultze-Lutter F, Keshavan M, Wood S, Ruhrmann S, Seidman LJ, Valmaggia L, Cannon T, Velthorst E, De Haan L, Cornblatt B, Bonoldi I, Birchwood M, McGlashan T, Carpenter W, McGorry P, Klosterkötter J, McGuire P, Yung A. The psychosis high-risk state: a comprehensive state-of-the-art review. JAMA Psychiatry 2013; 70:107-20. [PMID: 23165428 PMCID: PMC4356506 DOI: 10.1001/jamapsychiatry.2013.269] [Citation(s) in RCA: 964] [Impact Index Per Article: 87.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
CONTEXT During the past 2 decades, a major transition in the clinical characterization of psychotic disorders has occurred. The construct of a clinical high-risk (HR) state for psychosis has evolved to capture the prepsychotic phase, describing people presenting with potentially prodromal symptoms. The importance of this HR state has been increasingly recognized to such an extent that a new syndrome is being considered as a diagnostic category in the DSM-5. OBJECTIVE To reframe the HR state in a comprehensive state-of-the-art review on the progress that has been made while also recognizing the challenges that remain. DATA SOURCES Available HR research of the past 20 years from PubMed, books, meetings, abstracts, and international conferences. STUDY SELECTION AND DATA EXTRACTION Critical review of HR studies addressing historical development, inclusion criteria, epidemiologic research, transition criteria, outcomes, clinical and functional characteristics, neurocognition, neuroimaging, predictors of psychosis development, treatment trials, socioeconomic aspects, nosography, and future challenges in the field. DATA SYNTHESIS Relevant articles retrieved in the literature search were discussed by a large group of leading worldwide experts in the field. The core results are presented after consensus and are summarized in illustrative tables and figures. CONCLUSIONS The relatively new field of HR research in psychosis is exciting. It has the potential to shed light on the development of major psychotic disorders and to alter their course. It also provides a rationale for service provision to those in need of help who could not previously access it and the possibility of changing trajectories for those with vulnerability to psychotic illnesses.
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Affiliation(s)
- Paolo Fusar-Poli
- Department of Psychosis Studies, King's College London, London, UK.
| | - Stefan Borgwardt
- Department of Psychiatry, University of Basel, Basel, Switzerland
| | - Andreas Bechdolf
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | - Jean Addington
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | | | - Frauke Schultze-Lutter
- University Hospital of Child and Adolescent Psychiatry, University of Bern, Bern, Switzerland
| | - Matcheri Keshavan
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Stephen Wood
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, Australia; School of Psychology, University of Birmingham, Birmingham, United Kingdom
| | - Stephan Ruhrmann
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | - Larry J. Seidman
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston
| | - Lucia Valmaggia
- Departments of Psychosis Studies and Psychology, King's College London, London, United Kingdom; OASIS team for prodromal psychosis, NHSSLAM Foundation Trust, London
| | - Tyrone Cannon
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Eva Velthorst
- Department of Early Psychosis, Academic Medical Center, Amsterdam, the Netherlands
| | - Lieuwe De Haan
- Department of Early Psychosis, Academic Medical Center, Amsterdam, the Netherlands
| | - Barbara Cornblatt
- Department of Psychiatry Research, The Zucker Hillside Hospital, New York, New York
| | - Ilaria Bonoldi
- OASIS team for prodromal psychosis, NHSSLAM Foundation Trust, London; Department of Psychosis Studies King's College London, London, United Kingdom
| | - Max Birchwood
- School of Psychology, University of Birmingham, Birmingham, United Kingdom
| | | | - William Carpenter
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore
| | - Patrick McGorry
- Orygen Youth Health Research Centre, University of Melbourne, Melbourne
| | | | - Philip McGuire
- Department of Psychosis Studies King's College London, London, United Kingdom; OASIS team for prodromal psychosis, NHSSLAM Foundation Trust, London
| | - Alison Yung
- Orygen Youth Health Research Centre, University of Melbourne, Melbourne
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Mihalopoulos C, McCrone P, Knapp M, Johannessen JO, Malla A, McGorry P. The costs of early intervention in psychosis: restoring the balance. Aust N Z J Psychiatry 2012; 46:808-11. [PMID: 22956566 DOI: 10.1177/0004867412457999] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Services that provide comprehensive, early intervention (EI) have shown promise in improving long-term outcomes in schizophrenia. This article reviews the rationale and salient concepts relevant to understanding the growing EI literature. A selective review of studies evaluating the effectiveness of integrated EI is followed by a discussion of feasibility, especially in the US context. Finally, the authors present a framework that seeks to integrate activities traditionally categorized and separated as discovery and implementation. This framework is offered as a way to advance both goals.
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Affiliation(s)
- Vinod H Srihari
- Department of Psychiatry, Yale University,and Clinic for Specialized Treatment Early in Psychosis (STEP), 34 Park Street, Connecticut Mental Health Center, Room 273A, New Haven, CT 06519, USA.
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Abstract
OBJECTIVE Early-intervention units have proliferated over the last decade, justified in terms of cost as well as treatment effect. Strong claims for extension of these programmes on economic grounds motivate a systematic review of economic evaluations of early-intervention programmes. METHOD Searches were undertaken in the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and PsycINFO with keywords including 'early intervention', 'ultra-high risk', 'prodrome', 'cost-effectiveness', 'psychosis', 'economic', and 'at-risk mental state'. Relevant journals, editorials, and the references of retrieved articles were hand-searched for appropriate research. RESULTS Eleven articles were included in the review. The more rigorous research (two randomized control trials and two quasi-experimental studies) suggested no difference in resource utilization or costs between early-intervention and treatment-as-usual groups. One small case-control study with evidence of significant bias concluded annual early-intervention costs were one-third of treatment-as-usual costs. Modelling studies projected reduced costs of early intervention but were based on assumptions since definitively revised. Cost-effectiveness analyses did not strongly support the cost-effectiveness of early intervention. No studies appropriately valued outpatient costs or addressed the feasibility of realizing reduced hospitalization in reduced costs. CONCLUSIONS The published literature does not support the contention that early intervention for psychosis reduces costs or achieves cost-effectiveness. Past failed attempts to reduce health costs by reducing hospitalization, and increased outpatient costs in early-intervention programmes suggest such programmes may increase costs. Future economic evaluation of early-intervention programmes would need to correctly value outpatient costs and accommodate uncertainty regarding reduced hospitalization costs, perhaps by sensitivity analysis. The current research hints that cost differences may be greater early in treatment and in patients with more severe illness.
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Affiliation(s)
- Andrew Amos
- Department of Medicine, University of Queensland, Brisbane, Australia.
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Knapp M, McDaid D. Making an Economic Case for Prevention and Promotion. INTERNATIONAL JOURNAL OF MENTAL HEALTH PROMOTION 2012. [DOI: 10.1080/14623730.2009.9721792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Yung AR. Early intervention in psychosis: evidence, evidence gaps, criticism, and confusion. Aust N Z J Psychiatry 2012; 46:7-9. [PMID: 22247086 DOI: 10.1177/0004867411432205] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Alison R Yung
- ORYGEN Research Centre, Department of Psychiatry, Parkville, Australia.
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Chen EYH, Tang JYM, Hui CLM, Chiu CPY, Lam MML, Law CW, Yew CWS, Wong GHY, Chung DWS, Tso S, Chan KPM, Yip KC, Hung SF, Honer WG. Three-year outcome of phase-specific early intervention for first-episode psychosis: a cohort study in Hong Kong. Early Interv Psychiatry 2011; 5:315-23. [PMID: 21726421 DOI: 10.1111/j.1751-7893.2011.00279.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM Although phase-specific early intervention for first-episode psychosis has been implemented in many different parts of the world, limited medium-term outcome data are available in non-Western populations with relatively low mental health resources. The study aimed to determine the effectiveness of phase-specific early intervention in first-episode psychosis. METHOD In this cohort study, we compared the 3-year outcome of 700 first-episode psychosis patients who received phase-specific early intervention with that of 700 patients matched for age, sex and diagnosis who received standard psychiatric care prior to early intervention. Using a structured data acquisition procedure, we determined functional outcome, symptom levels, relapse, recovery, suicidal behaviour and service utilization from clinical records. RESULTS Patients in the early intervention group had longer full-time employment or study (P<0.001), fewer days of hospitalization (P<0.001), less severe positive symptoms (P=0.006), less severe negative symptoms (P =0.001), fewer suicides (P=0.009) and fewer disengagements (P=0.002) than the historical control group. Additionally, more patients in the early intervention group experienced a period of recovery (P=0.001), but the two groups had similar rates of relapse (P=0.08) and durations of untreated psychosis (P=0.72). CONCLUSIONS The 3-year outcome in phase-specific early intervention compared favourably with that of standard psychiatric care, particularly with respect to functional outcome and reduction in hospitalizations, suicides and disengagements. However, intervention did not appear to reduce the rate of relapse.
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Affiliation(s)
- Eric Y H Chen
- Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital Department of Psychiatry, Queen Mary Hospital, Pokfulam Road, Hong Kong.
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Wong KK, Chan SKW, Lam MML, Hui CLM, Hung SF, Tay M, Lee KH, Chen EYH. Cost-effectiveness of an early assessment service for young people with early psychosis in Hong Kong. Aust N Z J Psychiatry 2011; 45:673-80. [PMID: 21870925 DOI: 10.3109/00048674.2011.586329] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The Early Assessment Service for Young People with Early Psychosis (EASY) was developed in Hong Kong in 2001 to provide a comprehensive and integrated approach for early detection and intervention for young people suffering from first episode psychosis. The present study examined the cost-effectiveness of the service over a period of 24 months compared to standard care. METHOD This is a historical control study. Sixty-five patients who presented to the EASY service in 2001 with first episode psychosis were individually matched (on age, sex and diagnosis) with 65 patients who received standard psychiatric care in a precursor service (pre-EASY) between 1999 and 2000. A retrospective cost-effectiveness analysis was conducted over a period of 24 months. The overall average cost of service utilization per patient and the effects on hospitalization rate were compared using bootstrapping analysis. Cost per point improvement in Positive and Negative Syndrome Scale (PANSS) was also computed with sensitivity analysis. Only direct costs were analysed in the current study. RESULTS There was no significant difference in service utilization between the EASY and pre-EASY standard care groups. The cost-effectiveness acceptability curve, which was used to explore uncertainty in estimates of cost and effects, suggested that there was a probability of at least 94% that the EASY model was more cost-effective than the pre-EASY service in reducing psychiatric inpatient admissions. EASY patients also showed superior results in average cost per unit improvement in PANSS. CONCLUSIONS EASY is likely to be more cost-effective in improving outcomes, particularly in reducing hospitalization and improving clinical symptoms among young people with first episode psychosis. This study provides a perspective from the east Asian region, and supports further development of similar services, particularly in the local setting. However, further studies with a longer follow up period and larger sample size are required to verify these findings.
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Affiliation(s)
- Kenny K Wong
- Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, Pok Fu Lam Road, Hong Kong.
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Cocchi A, Mapelli V, Meneghelli A, Preti A. Cost-effectiveness of treating first-episode psychosis: five-year follow-up results from an Italian early intervention programme. Early Interv Psychiatry 2011; 5:203-11. [PMID: 21729243 DOI: 10.1111/j.1751-7893.2011.00261.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM Early intervention programmes are expected to result in the reduction of illness severity in patients with schizophrenia, and contain health-care costs by reducing hospital admissions and improving the social functioning of patients. This study aimed to investigate the cost-effectiveness of treatment in an early intervention programme in comparison to standard care. METHODS Retrospective analysis of data prospectively recorded in an urban area (Milan, Italy). Twenty-three patients from an early intervention programme and 23 patients from standard care with first-episode psychosis were evaluated on their use of services over a 5-year period. The Health of the Nation Outcome Scale was used to measure clinical status. RESULTS Significant changes with respect to initial assessment were recorded on the Health of the Nation Outcome Scale, with larger effect sizes in the early intervention programme than in the standard care group. Consequently, the cost-effectiveness ratio per reduced score of severity was lower in the early intervention programme than in standard care (€ 4802 vs. € 9871), with an incremental cost-effectiveness ratio, or net saving of €-1204 for every incremental reduced score of severity. Over time, greater recourse to hospital and residential facilities to obtain comparable improvement in symptoms resulted in a steady cost increase for the patients in standard care. CONCLUSIONS Allocation of funds to specialized early intervention programmes is the best alternative, as it can save costs by reducing the use of hospitals and residential facilities, and may produce net savings of costs in the long term.
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Affiliation(s)
- Angelo Cocchi
- Department of Mental Health, Center for early detection and intervention in psychosis-Programma2000, Niguarda Ca' Granda Hospital, Milan, Italy.
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Abstract
SummaryAims – Psychosis is a traumatic experience for both sufferers and their families. The morbidity and mortality associated with psychosis may be improved by an assertive, specialised, multidisciplinary approach to care, provided at the earliest opportunity. Early Intervention in Psychosis (EIP) uses such approach to improve the individual's short and long-term symptomatic and functional outcome, as well as quality of life. However, there is still controversy about whether this type of intervention is effective enough to justify its associated costs. Methods – We reviewed evidence from the literature on EIP for schizophrenia spectrum and non-affective psychoses, with particular attention to evidence on its effectiveness in reducing the duration of untreated symptoms, preventing relapses and reducing admission rates, reducing suicide rates, and reducing treatment costs. Results – There is preliminary evidence that EIP may be effective in delaying transition to psychosis, reducing DUP, preventing relapses, reducing admission and suicidal rates, and reducing treatment costs. Discussion – EIP remains a stimulating multidisciplinary approach to psychosis and a demanding commitment for mental health professionals and service developers.Declaration of Interest: None.
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Yung AR, Wood SJ, McGorry PD, Pantelis C. Commentary on ''Should the diagnostic boundaries of schizophrenia be expanded?''. Cogn Neuropsychiatry 2011; 16:107-12. [PMID: 21390929 DOI: 10.1080/13546805.2011.554284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- A R Yung
- Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia.
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Murphy BP. Beyond the first episode: candidate factors for a risk prediction model of schizophrenia. Int Rev Psychiatry 2010; 22:202-23. [PMID: 20504060 DOI: 10.3109/09540261003661833] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Many early psychosis services are financially compromised and cannot offer a full tenure of care to all patients. To maintain viability of services it is important that those with schizophrenia are identified early to maximize long-term outcomes, as are those with better prognoses who can be discharged early. The duration of untreated psychosis remains the mainstay in determining those who will benefit from extended care, yet its ability to inform on prognosis is modest in both the short and medium term. There are a number of known or putative genetic and environmental risk factors that have the potential to improve prognostication, though a multivariate risk prediction model combining them with clinical characteristics has yet to be developed. Candidate risk factors for such a model are presented, with an emphasis on environmental risk factors. More work is needed to corroborate many putative factors and to determine which of the established factors are salient and which are merely proxy measures. Future research should help clarify how gene-environment and environment-environment interactions occur and whether risk factors are dose-dependent, or if they act additively or synergistically, or are redundant in the presence (or absence) of other factors.
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Affiliation(s)
- Brendan P Murphy
- Recovery and Prevention of Psychosis Service, Southern Health, Melbourne, Victoria, Australia.
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Cleary M, Hunt G, O'Connor N, Snars J. The Concord Centre for Mental Health's new 'phase of illness' model of care: are we on the right track? Australas Psychiatry 2010; 18:246-9. [PMID: 20482428 DOI: 10.3109/10398561003686755] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to provide an overview of a new 'phase of illness' model of care after relocation of Rozelle Hospital to the new purpose built Concord Centre for Mental Health and discuss its implementation and progress thus far. METHOD One year after relocation, staff were asked to provide feedback of their views of the new model of care in order to identify implementation barriers and ways forward. RESULTS The new model has clear benefits for the consumer, but there are a number of practical challenges and dilemmas emerging that necessitate some refinement and evaluation. Feedback from staff provided a wide range of opinions indicating that some were quite cynical of the new model while others were very supportive and thought that patient care was enhanced. CONCLUSIONS Further development and consolidation of the model is required, including more education sessions and a clear mission statement at unit, hospital and community levels. Further research is also required to assess the impact and ability of the new model to deliver better patient outcomes, especially in regard to continuity of care.
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Affiliation(s)
- Michelle Cleary
- School of Nursing & Midwifery, University of Western Sydney, NSW, Australia.
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Abstract
Early intervention in psychosis services produce better clinical outcomes than generic teams and are also cost-effective. Clinical gains made within such services are robust as long as the interventions are actively provided. Longer-term data show that some of these gains are lost when care is transferred back to generic teams. This paper argues that sustaining these early gains requires both a reappraisal of generic services and an understanding of the active ingredients of early intervention, which can be tailored for longer input in cases with poorer outcome trajectories.
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Affiliation(s)
- Swaran P Singh
- Health Sciences Research Institute, Medical School Building, University of Warwick, Coventry CV4 7AL, UK.
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McCrone P, Craig TKJ, Power P, Garety PA. Cost-effectiveness of an early intervention service for people with psychosis. Br J Psychiatry 2010; 196:377-82. [PMID: 20435964 DOI: 10.1192/bjp.bp.109.065896] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is concern that delaying treatment for psychosis may have a negative impact on its long-term course. A number of countries have developed early intervention teams but there is limited evidence regarding their cost-effectiveness. AIMS To compare the costs and cost-effectiveness of an early intervention service in London with standard care. METHOD Individuals in their first episode of psychosis (or those who had previously discontinued treatment) were recruited to the study. Clinical variables and costs were measured at baseline and then at 6- and 18-month follow-up. Information on quality of life and vocational outcomes were combined with costs to assess cost-effectiveness. RESULTS A total of 144 people were randomised. Total mean costs were 11,685 pounds sterling in the early intervention group and 14,062 pounds sterling in the standard care group, with the difference not being significant (95% CI -8128 pounds sterling to 3326 pounds sterling). When costs were combined with improved vocational and quality of life outcomes it was shown that early intervention would have a very high likelihood of being cost-effective. CONCLUSIONS Early intervention did not increase costs and was highly likely to be cost-effective when compared with standard care.
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Affiliation(s)
- Paul McCrone
- Centre for the Economics of Mental Health, PO 24, Health Service and Population Research Department, Institute of Psychiatry, King's College London, London SE5 8AF, UK.
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Catts SV, O'Toole BI, Carr VJ, Lewin T, Neil A, Harris MG, Frost ADJ, Crissman BR, Eadie K, Evans RW. Appraising evidence for intervention effectiveness in early psychosis: conceptual framework and review of evaluation approaches. Aust N Z J Psychiatry 2010; 44:195-219. [PMID: 20180724 DOI: 10.3109/00048670903487167] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The literature that is relevant to evaluation of treatment effectiveness is large, scattered and difficult to assemble for appraisal. This scoping review first develops a conceptual framework to help organize the field, and second, uses the framework to appraise early psychosis intervention (EPI) studies. Literature searches were used to identify representative study designs, which were then sorted according to evaluation approach. The groupings provided a conceptual framework upon which a map of the field could be drawn. Key words were cross-checked against definitions in dictionaries of scientific terms and the National Library of Medicine Medical Subject Headings (MeSH) browser. Using the final list of key words as search terms, the EPI evaluation literature was appraised. Experimental studies could be grouped into two classes: efficacy and effectiveness randomized controlled trials. Non-experimental studies could be subgrouped into at least four overlapping categories: clinical epidemiological; health service evaluations; quality assurance studies; and, quasi-experimental assessments of treatment effects. Applying this framework to appraise EPI studies indicated promising evidence for the effectiveness of EPI irrespective of study design type, and a clearer picture of where future evaluation efforts should be focused. Reliance on clinical trials alone will restrict the type of information that can inform clinical practice. There is convergent evidence for the benefits of specialized EPI service functions across a range of study designs. Greater investment in health services research and quality assurance approaches in evaluating EPI effectiveness should be made, which will involve scaling up of study sizes and development of an EPI programme fidelity rating template. The degree of complexity of the evaluation field suggests that greater focus on research methodology in the training of Australasian psychiatrists is urgently needed.
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Affiliation(s)
- Stanley V Catts
- School of Medicine, University of Queensland, K Floor, Mental Health Centre, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia.
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Catts SV, Evans RW, O'Toole BI, Carr VJ, Lewin T, Neil AL, Harris MG, Frost ADJ, Crissman BR, Eadie K. Is a national framework for implementing early psychosis services necessary? Results of a survey of Australian mental health service directors. Early Interv Psychiatry 2010; 4:25-30. [PMID: 20199477 DOI: 10.1111/j.1751-7893.2009.00157.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM Expert opinion holds that the rate of implementation of specialist services for first presentation psychosis in Australia is much too slow. We aimed to collect evidence regarding this view from the first national survey of adult public mental health services about their self-reported efforts to implement specialist early psychosis intervention (EPI). METHODS Using a purpose-designed Census form for assessing EPI implementation, adult public mental health service directors throughout Australia were asked about EPI-relevant local service activities. RESULTS Sixty Census forms were returned (response rate = 61%), representing a total catchment population of 12.5 million people. A minority of services reported high levels of EPI implementation, which varied widely between area services and across state and territory jurisdictions. Rural and remote services were overrepresented in the lowest levels of reported EPI implementation. Only one service characteristic, the value of identifiable funding committed specifically to EPI, was predictive of level of reported EPI implementation. CONCLUSIONS The disturbingly high levels of variability in EPI implementation across jurisdictions suggest a pressing need for a set of nationally agreed uniform EPI implementation standards. Additional specific strategies for rural and remote mental health services may be needed for these services to implement EPI.
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Affiliation(s)
- Stanley V Catts
- Discipline of Psychiatry, University of Queensland, Queensland, Australia.
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Fowler D, Hodgekins J, Howells L, Millward M, Ivins A, Taylor G, Hackmann C, Hill K, Bishop N, Macmillan I. Can targeted early intervention improve functional recovery in psychosis? A historical control evaluation of the effectiveness of different models of early intervention service provision in Norfolk 1998-2007. Early Interv Psychiatry 2009; 3:282-8. [PMID: 22642731 DOI: 10.1111/j.1751-7893.2009.00146.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS This paper assesses the impact of different models of early intervention (EI) service provision on functional recovery and inpatient hospital admission. The study compares the outcome of a comprehensive EI team with a partial model (community mental health team (CMHT) plus specialist support) and traditional care (generic CMHT) over a 10-year period. METHODS The design is in comparison with historical control. The study compares the functional recovery outcomes of three cohorts from the same geographical area over the period 1998-2007. The primary outcomes were partial and full functional recovery defined with respect to readily identifiable UK benefit system thresholds and psychiatric inpatient admission days at 1 and 2 years post-referral. RESULTS Only 15% of individuals made a full or partial functional recovery at 2 years under the care of a traditional generic CMHT in 1998. In 2007, 52% of the cases were making a full or partial functional recovery under the care of the comprehensive EI team. A large reduction in inpatient admissions was associated with the EI strategy. CONCLUSIONS The implementation of comprehensive EI teams can have a major impact in improving functional recovery outcomes in psychosis and reducing inpatient admissions. Partial implementation using limited funding of specialist workers in collaboration with traditional care appeared to have a more limited effect on these recovery dimensions. The implementation of targeted EI in psychosis strategies can result in substantive functional benefits.
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Affiliation(s)
- David Fowler
- Early Intervention Service, Norfolk and Waveney Mental Health Foundation NHS Trust, Norwich, UK.
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Srihari VH, Breitborde NJK, Pollard J, Tek C, Hyman L, Frisman LK, McGlashan TH, Jacobs S, Woods SW. Public-academic partnerships: early intervention for psychotic disorders in a community mental health center. Psychiatr Serv 2009; 60:1426-8. [PMID: 19880454 PMCID: PMC4469899 DOI: 10.1176/appi.ps.60.11.1426] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Early intervention may improve long-term outcomes for psychotic illnesses. Early-intervention services in other countries have focused on reducing the duration of untreated illness and adapting interventions for younger patients. This column describes the process of building such a service, called specialized treatment early in psychosis (STEP), at the Connecticut Mental Health Center. This effort is rooted in a long-standing collaborative relationship between the Connecticut Department of Mental Health and Addiction Services and Yale. The authors describe the critical contribution of such partnerships in evaluating the cost-effectiveness of early intervention in a "real-world" U.S. setting.
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Affiliation(s)
- Vinod H Srihari
- Connecticut Mental Health Center, Yale University School of Medicine, New Haven, CT 06519, USA.
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McCrone P, Knapp M, Dhanasiri S. Economic impact of services for first-episode psychosis: a decision model approach. Early Interv Psychiatry 2009; 3:266-73. [PMID: 22642729 DOI: 10.1111/j.1751-7893.2009.00145.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To assess the impact of early intervention (EI) services on service costs for people with first-episode psychosis. METHODS A decision model was constructed to map the care pathways following input from EI services and from standard care. A Markov process was used to run the model over 18 2-month cycles. Probabilities and costs for the model of admissions, readmissions and use of community services were obtained from the literature, routine sources and expert opinion. One-way and probabilistic sensitivity analyses were conducted to address uncertainty around the parameter estimates. RESULTS The model estimated 1 year costs to be £9422 for EI and £14,394 for standard care. The respective figures over 3 years were £26,568 and £40,816. One-way sensitivity analyses revealed that the results were robust to changes in most parameters with the exception of the readmission rate. A relatively small decrease in the readmission rate for standard care patients would eliminate the cost saving. The probabilistic sensitivity analyses also showed that the results were robust to parameter changes. CONCLUSIONS This study suggests cost savings associated with EI. However, caution is required as the model is relatively simple and relies on a number of assumptions.
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Affiliation(s)
- Paul McCrone
- Institute of Psychiatry, King's College London, London, UK.
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Valmaggia LR, McCrone P, Knapp M, Woolley JB, Broome MR, Tabraham P, Johns LC, Prescott C, Bramon E, Lappin J, Power P, McGuire PK. Economic impact of early intervention in people at high risk of psychosis. Psychol Med 2009; 39:1617-1626. [PMID: 19356258 DOI: 10.1017/s0033291709005613] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Despite the increasing development of early intervention services for psychosis, little is known about their cost-effectiveness. We assessed the cost-effectiveness of Outreach and Support in South London (OASIS), a service for people with an at-risk mental state (ARMS) for psychosis. METHOD The costs of OASIS compared to care as usual (CAU) were entered in a decision model and examined for 12- and 24-month periods, using the duration of untreated psychosis (DUP) and rate of transition to psychosis as key parameters. The costs were calculated on the basis of services used following referral and the impact on employment. Sensitivity analysis was used to test the robustness of all the assumptions made in the model. RESULTS Over the initial 12 months from presentation, the costs of the OASIS intervention were pound1872 higher than CAU. However, after 24 months they were pound961 less than CAU. CONCLUSIONS This model suggests that services that permit early detection of people at high risk of psychosis may be cost saving.
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Affiliation(s)
- L R Valmaggia
- OASIS and Department of Psychological Medicine, Institute of Psychiatry, King's College London, UK.
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Mihalopoulos C, Harris M, Henry L, Harrigan S, McGorry P. Is early intervention in psychosis cost-effective over the long term? Schizophr Bull 2009; 35:909-18. [PMID: 19509308 PMCID: PMC2728818 DOI: 10.1093/schbul/sbp054] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study assesses the long-term cost-effectiveness of a comprehensive model of mental health care for first-episode psychosis. The study is an extension of a previous economic evaluation of the Early Psychosis Prevention and Intervention Centre (EPPIC) that assessed the first-year costs and outcomes of treatment. METHOD The current study used a matched, historical control group design with a follow-up of approximately 8 years. Complete follow-up data were available for 65 of the original 102 participants. Direct public mental health service costs incurred subsequent to the first year of treatment and symptomatic and functional outcomes of 32 participants initially treated for up to 2 years at EPPIC were compared with a matched cohort of 33 participants initially treated by generic mental health services. Treatment-related resource use was measured and valued using Australian published prices. RESULTS Almost 8 years after initial treatment, EPPIC subjects displayed lower levels of positive psychotic symptoms (P = .007), were more likely to be in remission (P = .008), and had a more favorable course of illness (P = .011) than the controls. Fifty-six percent of the EPPIC cohort were in paid employment over the last 2 years compared with 33% of controls (P = .083). Each EPPIC patient costs on average A$3445 per annum to treat compared with controls, who each costs A$9503 per annum. CONCLUSIONS Specialized early psychosis programs can deliver a higher recovery rate at one-third the cost of standard public mental health services. Residual methodological limitations and limited sample size indicate that further research is required to verify this finding.
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Affiliation(s)
- Cathrine Mihalopoulos
- Deakin Health Economics, Deakin University, 221 Burwood Highway, Burwood, Victoria 3125, Australia.
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Chong SA, Verma S, Mythily S, Poon LY, McGorry PD. The Early Psychosis Intervention Programme in Singapore: A balanced scorecard approach to quality care. J Ment Health 2009. [DOI: 10.1080/09638230701530200] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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