Cost-effectiveness of early intervention in psychosis: systematic review

Economics and mental health: the current scenario

Economics and mental health are intertwined. Apart from the accumulating evidence of the huge economic impacts of mental ill-health, and the growing recognition of the effects that economic circumstances can exert on mental health, governments and other budget-holders are putting increasing emphasis on economic data to support their decisions. Here we consider how economic evaluation (including cost-effectiveness analysis, cost-utility analysis and related techniques) can contribute evidence to inform the development of mental health policy strategies, and to identify some consequences at the treatment or care level that are of relevance to service providers and funding bodies. We provide an update and reflection on economic evidence relating to mental health using a lifespan perspective, analyzing costs and outcomes to shed light on a range of pressing issues. The past 30 years have witnessed a rapid growth in mental health economics, but major knowledge gaps remain. Across the lifespan, clearer evidence exists in the areas of perinatal depression identification-plus-treatment; risk-reduction of mental health problems in childhood and adolescence; scaling up treatment, particularly psychotherapy, for depression; community-based early intervention and employment support for psychosis; and cognitive stimulation and multicomponent carer interventions for dementia. From this discussion, we pull out the main challenges that are faced when trying to take evidence from research and translating it into policy or practice recommendations, and from there to actual implementation in terms of better treatment and care.

The Ohio State University Early Psychosis Intervention Center (EPICENTER) step-based care programme for individuals at clinical high risk for psychosis: study protocol for an observational study

INTRODUCTION

In October 2018, the Substance Abuse and Mental Health Services Administration funded 21 sites throughout the USA to develop, implement and evaluate specialised care programmes for individuals at clinical high risk for developing a psychotic disorder (CHR-P). Per the funding requirements, such programmes were required to provide 'step-based care'-a model in which individuals are initially provided with low-intensity, non-psychosis-specific and more benign (ie, least side effects) interventions and only progress onto higher-intensity, psychosis-specific interventions with a greater risk of more severe side effects should they not meet a priori criteria for clinical response to such lower-intensity interventions. Here, we outline the evaluation component of the step-based care programme for individuals at CHR-P at The Ohio State University Early Psychosis Intervention Center (EPICENTER).

METHODS AND ANALYSES

The EPICENTER CHR-P programme provides a step-based care model comprising psychotherapy, medication management, family support/education, peer support and vocational/educational support. All participants who opt to receive care at the EPICENTER will complete a standardised assessment battery as part of usual care. This battery will be administered on enrolment and will be re-administered at 6-month intervals throughout individuals' participation in EPICENTER clinical services. Participants will have the opportunity to allow for data from these usual care assessments to be used as part of an evaluation project for this new clinical service. The primary outcome for this evaluation project is time to remission of symptomatic and functional deficits commonly experienced by individuals at CHR-P. Participants will also have the opportunity to participate in a supplemental research project designed to further evaluate treatment outcomes and patient characteristics among individuals participating in EPICENTER clinical services.

ETHICS AND DISSEMINATION

This project was approved by The Ohio State University Institutional Review Board. Results from this project will be disseminated through publications and presentations.

TRIAL REGISTRATION NUMBER

NCT03970005; Pre-results.

Young Patients With Persistent and Complex Care Needs Require an Integrated Care Approach: Baseline Findings From the Multicenter Youth Flexible ACT Study

Background: The Multicenter Youth Flexible ACT Study is an ongoing observational prospective cohort study that examines the effects of Youth Flexible ACT (Assertive Community Treatment) on young people with complex care needs who are difficult to engage in traditional (office-based) mental health services. However, a clear and detailed description of this patient group is lacking. In the current paper, we present baseline characteristics and psychosocial outcomes of the Youth Flexible ACT target group and explore the existence of underlying specific patient subgroups. Methods: Sixteen Youth Flexible ACT teams from seven mental healthcare institutes in the Netherlands participated in the study. Research participants were monitored for 18 months and administered questionnaires measuring psychiatric- and social functioning every 6 months, yielding four measurements. Baseline data were obtained from 199 adolescents, their mental health workers, and parents/carers. Latent Class Analysis based on HoNOSCA scores (measuring psychosocial and daily functioning) was conducted to identify underlying subgroups. Results: The target group of Youth Flexible ACT mainly consisted of patients older than 15 years of age with a history of (specialized) mental healthcare. They face many complex problems, including trauma; developmental, mood, and anxiety disorders; and problems with school attendance, family life, and peer relationships. Other frequently reported difficulties were substance misuse, the involvement of the legal system or police, problems with intellectual functioning, and personal finance. Patients were classified into four distinct classes: the "internalizing," "externalizing," "non-specific," and the "overly impulsive" subgroup. Each subgroup had its unique pattern of difficulties and focus, respectively, high levels of depression and anxiety, disruptive behavior, unspecific difficulties, and substance misuse. Conclusions: As expected, patients in Youth Flexible ACT experienced many severe problems, rendering them vulnerable to fragmented and, thus, ineffective care. Our findings underscore the need for an integrated care approach with a multidisciplinary team of skilled professionals that can bridge these wide-ranging psychosocial problems, as each class of participants experienced a different set of difficulties. Youth Flexible ACT teams need to adjust their care services accordingly.

Early intervention services for non-psychotic mental health disorders: a scoping review protocol

INTRODUCTION

Worldwide mental health disorders are associated with a considerable amount of human suffering, disability and mortality. Yet, the provision of rapid evidence-based care to mitigate the human and economic costs of these disorders is limited. The greatest progress in developing and delivering early intervention services has occurred within psychosis. There is now growing support for and calls to extend such approaches to other diagnostic groups. The aim of this scoping review is to systematically map the emerging literature on early intervention services for non-psychotic mental health disorders, with a focus on outlining how services are structured, implemented and scaled.

METHODS AND ANALYSIS

The protocol was developed using the guidance for scoping reviews in the Joanna Briggs Institute manual and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews checklist. A systematic search for published and unpublished literature will be conducted using the following databases: (1) MEDLINE, (2) PsycINFO, (3) HMIC, (4) EMBASE and (5) ProQuest. To be included, documents must describe and/or evaluate an early intervention service for adolescents or adults with a non-psychotic mental health disorder. There will be no restrictions on publication type, study design and date. Title and abstract, and full-text screening will be completed by one reviewer, with a proportion of articles screened in duplicate. Data analysis will primarily involve a qualitatively summary of the early intervention literature, the characteristics of early intervention services and key findings relating to their evaluation and implementation.

ETHICS AND DISSEMINATION

The synthesis of published and unpublished articles will not require ethical approval. The results of this scoping review will be published in a peer-reviewed journal and disseminated via social media, conference presentations and other knowledge translation activities.

Early intervention services for psychosis in Ireland: are we there yet?

Early intervention in psychosis (EIP) services are now a priority for Ireland’s Health Service Executive (HSE). A Model of Care for EIP services has been completed after wide consultation. It has just been launched by the Minister for Mental Health and the aim now is to roll out EIP services throughout the country. The Model of Care outlines the rational, configuration, resources, governance, and quality assurance required to operate EIP services. Two models are recommended. The first is a Hub & Spoke service model for rural and smaller urban areas. The second is a Stand-Alone service model for large urban and metropolitan areas. Introducing EIP services is going to be a challenge but there are plenty of good examples overseas. They have been shown to greatly enhance local services’ ability to meet the needs of people developing psychotic disorders. They bring with them better outcomes, service satisfaction and cost savings.

A Public Health Perspective on Screening for Psychosis Within General Practice Clinics

Screening for major mental illness in adolescents and young adults has lagged behind screening for physical illness for a myriad of reasons. Existing pediatric behavioral health screening tools screen primarily for disorders of attention, disruptive behaviors, depression, and anxiety. A few also screen for substance use and suicide risk. Although it is now possible to reliably identify young people at imminent risk for a psychotic disorder, arguably the most severe of mental illnesses, general practitioners (GP) rarely screen for psychotic symptoms or recognize when to refer patients for a specialized risk assessment. Research suggests that barriers such as inadequate knowledge or insufficient access to mental health resources can be overcome with intensive GP education and the integration of physical and mental health services. Under the lens of two public health models outlining the conditions under which disease screening is warranted, we examine additional evidence for and against population-based screening for psychosis in adolescents and young adults. We argue that systematic screening within general health settings awaits a developmentally well-normed screening tool that includes probes for psychosis, is written at a sufficiently low reading level, and has acceptable sensitivity and, in particular, specificity for detecting psychosis and psychosis risk in both adolescents and young adults. As integrated healthcare models expand around the globe and psychosis-risk assessments and treatments improve, a stratified screening and careful risk management protocol for GP settings could facilitate timely early intervention that effectively balances the benefit/risk ratio of employing such a screening tool at the population level.