A first step in system improvement: a survey of Early Psychosis Intervention Programmes in Ontario

Early Psychosis Intervention and Primary Care: A Mixed Methods Study of Family Physician Knowledge, Attitudes, Preferences, and Needs

Family physicians (FPs) play an important but underappreciated role in the pathways to care for people with early psychosis. We conducted a mixed-methods study to describe the knowledge, attitudes, preferences, and needs of FPs towards the recognition and management of early psychosis. We sent a cross-sectional postal survey to a random sample of FPs in Ontario, Canada, and conducted in-depth qualitative interviews with twenty. FPs were generally aware of important early psychosis symptoms, however, there were some knowledge gaps. Among surveyed FPs, 25% were unsure of the availability of early psychosis intervention services in their region, and most (80%) would prefer to co-manage with specialists. In the qualitative interviews, FPs expressed varied comfort levels in recognizing psychosis, and that timely access to psychiatry was a main concern. Our findings suggest that FPs require better support in recognizing and managing early psychosis and facilitating connections with specialized care.

Exploring service user perspectives of behavioural family therapy in early intervention in psychosis

AIMS

Family intervention (FI) is recommended in national guidance to be offered to all service users accessing an early intervention in psychosis (EIP) team, due to the consistent evidence base in reducing relapse and rehospitalisation rates. However, FI implementation is poor nationally. Although barriers have been identified at the level of staff member and the organisation, there is a paucity of research identifying service user perspectives.

METHODS

A qualitative questionnaire design was used to explore service user perspectives of behavioural family therapy (BFT) within a specialist EIP service in northwest England.

RESULTS

Most participants contacted reported they lacked knowledge and understanding of BFT, with 54% reporting that this intervention had not been offered to them. This finding was unexpected and is inconsistent with the offer of BFT documentation in their clinical notes. Reasons for accepting BFT included to increase understanding of family members and for them to also be supported. Reasons for declining BFT included a preference for one-to-one interventions and not wanting family involved in their care.

CONCLUSIONS

National guidance on FI for psychosis is not reliably being translated to clinical practice, with many participants reporting that they were not offered this intervention. A key factor in accepting or declining an offer of BFT appeared to be whether participants wanted family members to be involved in their care. A lack of understanding of the BFT approach was evident, it is recommended that the offer of FI in psychosis is improved for service users to make an informed decision.

Economic Evaluation of Early Psychosis Interventions From A Canadian Perspective

BACKGROUND

Compared to treatment as usual (TAU), early psychosis intervention programs (EPI) have been shown to reduce mortality, hospitalizations and days of assisted living while improving employment status.

AIMS

The study aim was to conduct a cost-benefit analysis (CBA) and a cost-effectiveness analysis (CEA) to compare EPI and TAU in Canada.

METHODS

A decision-analytic model was used to estimate the 5-year costs and benefits of treating patients with a first episode of psychosis with EPI or TAU. EPI benefits were derived from randomized controlled trials (RCTs) and Canadian administrative data. The cost of EPI was based on a published survey of 52 EPI centers in Canada while hospitalizations, employment and days of assisted living were valued using Canadian unit costs. The outcomes of the CBA and CEA were expressed in terms of net benefit (NB) and incremental cost per life year gained (LYG), respectively. Scenario analyses were conducted to examine the impact of key assumptions. Costs are reported in 2019 Canadian dollars.

RESULTS

Base case results indicated that EPI had a NB of $85,441 (95% CI: $41,140; $126,386) compared to TAU while the incremental cost per LYG was $26,366 (95% CI: EPI dominates TAU (less costs, more life years); $102,269). In all sensitivity analyses the NB of EPI remained positive and the incremental cost per LYG was less than $50,000.

CONCLUSIONS

In addition to EPI demonstrated clinical benefits, our results suggest that large-scale implementation of EPI in Canada would be desirable from an economic point of view .

The Impact of Policy Changes, Dedicated Funding and Implementation Support on Early Intervention Programs for Psychosis

INTRODUCTION

Early intervention services for psychosis (EIS) are associated with improved clinical and economic outcomes. In Quebec, clinicians led the development of EIS from the late 1980s until 2017 when the provincial government announced EIS-specific funding, implementation support and provincial standards. This provides an interesting context to understand the impacts of policy commitments on EIS. Our primary objective was to describe the implementation of EIS three years after this increased political involvement.

METHODS

This cross-sectional descriptive study was conducted in 2020 through a 161-question online survey, modeled after our team's earlier surveys, on the following themes: program characteristics, accessibility, program operations, clinical services, training/supervision, and quality assurance. Descriptive statistics were performed. When relevant, we compared data on programs founded before and after 2017.

RESULTS

Twenty-eight of 33 existing EIS completed the survey. Between 2016 and 2020, the proportion of Quebec's population having access to EIS rose from 46% to 88%; >1,300 yearly admissions were reported by surveyed EIS, surpassing governments' epidemiological estimates. Most programs set accessibility targets; adopted inclusive intake criteria and an open referral policy; engaged in education of referral sources. A wide range of biopsychosocial interventions and assertive outreach were offered by interdisciplinary teams. Administrative/organisational components were less widely implemented, such as clinical/administrative data collection, respecting recommended patient-to-case manager ratios and quality assurance.

CONCLUSION

Increased governmental implementation support including dedicated funding led to widespread implementation of good-quality, accessible EIS. Though some differences were found between programs founded before and after 2017, there was no overall discernible impact of year of implementation. Persisting challenges to collecting data may impede monitoring, data-informed decision-making, and quality improvement. Maintaining fidelity and meeting provincial standards may prove challenging as programs mature and adapt to their catchment area's specificities and as caseloads increase. Governmental incidence estimates may need recalculation considering recent epidemiological data.

Diagnosed Incidence of Non-Affective Psychotic Disorders Amongst Adolescents in British Columbia and Sociodemographic Risk Factors: A Retrospective Cohort Study

OBJECTIVES

To estimate the diagnosed incidence of non-affective psychotic disorder between the ages of 13 and 19 years in South-Western British Columbia (BC) and to examine variation in risk by sex, family and neighbourhood income, family migration background, parent mental health contact and birth year.

METHODS

Linked individual-level administrative data were used to construct a cohort of individuals born in 1990-1998 and residing in South-Western BC (n = 193,400). Cases were identified by either one hospitalization or two outpatient physician visits within 2 years with a primary diagnosis of a non-affective psychotic disorder (ICD-10: F20-29, ICD-9: 295, 297, 298). We estimated cumulative incidence, annual cumulative incidence and incidence rate between the ages of 13 and 19 years, and conducted Cox proportional hazards regression to estimate associations between sociodemographic factors and risk over the study period.

RESULTS

We found that 0.64% of females and 0.88% of males were diagnosed with a non-affective psychotic disorder between the ages of 13 and 19 years, with increasing risk observed over the age range, especially amongst males. Incidence rate over the entire study period was 106 per 100,000 person-years for females and 145 per 100,000 person-years for males. Risk of diagnosis was elevated amongst those in low-income families and neighbourhoods, those with a parent who had a health service contact for a mental disorder, and more recent birth cohorts. Risk was reduced amongst children of immigrants compared to children of non-migrants.

CONCLUSIONS

Findings from this study provide important information for health service planning in South-Western BC. Future work should examine whether variations in diagnosed incidence is driven by differences in health service engagement or reflect genuine differences in risk.

A Rapid Learning Health System to Support Implementation of Early Intervention Services for Psychosis in Quebec, Canada: Study Protocol. (Preprint)

Background

Given the strong evidence of their effectiveness, early intervention services (EIS) for psychosis are being widely implemented. However, heterogeneity in the implementation of essential components remains an ongoing challenge. Rapid-learning health systems (RLHSs) that embed data collection in clinical settings for real-time learning and continuous quality improvement can address this challenge. Therefore, we implemented an RLHS in 11 EIS in Quebec, Canada.

Objective

This project aims to determine the feasibility and acceptability of implementing an RLHS in EIS and assess its impact on compliance with standards for essential EIS components.

Methods

Funding for this project was secured in July 2019, and ethics approval was received in December 2019. The implementation of this RLHS involves 6 iterative phases: external and internal scan, design, implementation, evaluation, adjustment, and dissemination. Multiple stakeholder groups (service users, families, clinicians, researchers, decision makers, and provincial EIS associations) are involved in all phases. Meaningful EIS quality indicators (eg, satisfaction and timeliness of response to referrals) were selected based on a literature review, provincial guidelines, and stakeholder consensus on prioritization of indicators. A digital infrastructure was designed and deployed comprising a user-friendly interface for routinely collecting data from programs; a digital terminal and mobile app to collect feedback from service users and families regarding care received, health, and quality of life; and data analytic, visualization, and reporting functionalities to provide participating programs with real-time feedback on their ongoing performance in relation to standards and to other programs, including tailored recommendations. Our community of practice conducts activities, leveraging insights from data to build program capacity while continuously aligning their practices with standards and best practices. Guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, we are collecting quantitative and qualitative data on the reach, effectiveness, adoption, implementation, and maintenance of our RLHS for evaluating its impacts.

Results

Phase 1 (identifying RLHS indicators for EIS based on a literature synthesis, a survey, and consensus meetings with all stakeholder groups) and phase 2 (developing and implementing the RLHS digital infrastructure) are completed (September 2019 to May 2020). Phases 3 to 5 have been ongoing (June 2020 to June 2022). Continuous data collection through the RLHS data capture platforms and real-time feedback to all stakeholders are deployed. Phase 6 will be implemented in 2022 to assess the impact of the RLHS using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework with quantitative and qualitative data.

Conclusions

This project will yield valuable insights into the implementation of RLHS in EIS, offering preliminary evidence of its acceptability, feasibility, and impacts on program-level outcomes. The findings will refine our RLHS further and advance approaches that use data, stakeholder voices, and collaborative learning to improve outcomes and quality in services for psychosis.

International Registered Report Identifier (IRRID)

DERR1-10.2196/37346

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evidence base for early intervention in psychosis services in rural areas: A critical review

AIM

Early Intervention in Psychosis teams (EITs) are a growing entity internationally, yet they remain under-researched given challenges facing their delivery. Model adaptations include stand-alone services, a hub-and-spoke model with various bases and integrating specialist staff into existing mental health teams. The present critical review focuses on reviewing the evidence base for the delivery of EITs in rural areas, first pertaining to evidence for model adherence and second to clinically outcomes.

METHOD

A systematic literature search was undertaken, finding 53 papers of interest. Nine papers met the inclusion criteria. A critical appraisal tool was used to consider the quality of the evidence and a narrative review of their findings is presented.

RESULTS

The five studies reporting clinical outcomes of rural EITs demonstrate positive outcomes of a hub-and-spoke and stand-alone EIT on reducing hospital admissions, psychotic symptoms and improving quality of life. One study directly comparing hub-and-spoke to stand-alone EIT found that hub-and-spoke EIT had more positive outcomes than a stand-alone service. Of the studies attempting to promote adherence to EIT model in rural areas, services show low overall adherence and report issues pertaining to funding and managerial support for practical barriers to implementation.

CONCLUSIONS

EIT services in rural areas may show similar positive outcomes to urban areas and adaptations to suit rural populations appear acceptable, such as using a hub-and-spoke model, though further research is required. Adherence to EIT service models in rural areas may be limited and training programmes to promote adherence benefit from managerial and financial support.

Feasibility and acceptability of a volunteer peer fidelity assessment model in early psychosis intervention programmes in Ontario: Results from a pilot study

AIM

Fidelity monitoring can support high-quality service delivery but is resource-intensive to implement. A fidelity assessment model utilizing volunteer assessors was trialled as a low-cost strategy for conducting fidelity assessments. This article reports on the acceptability and feasibility of this model.

METHODS

Twenty volunteer assessors were trained to conduct fidelity assessments in nine Early Psychosis Intervention programmes across Ontario, Canada. Assessments were conducted using the First-Episode Psychosis Services Fidelity Scale based on a 2-day site visit, during which assessors interviewed staff, clients and families; reviewed charts; observed a team meeting and reviewed programme materials. The model was evaluated based on assessor focus groups, programme interviews, consensus meeting data and time-tracking logs. General inductive analysis was used to code and synthesize qualitative data. Quantitative data were aggregated and summarized.

RESULTS

Participant feedback was positive and indicated that use of peer assessors and the in-person site visit added value to the process. The model was perceived to provide valuable information to support internal quality improvement efforts. Assessors reported direct benefits from participating, including networking and learning opportunities. Key challenges were the high time demand on assessors and turnover in the assessor team.

CONCLUSIONS

The volunteer peer fidelity model was perceived to be a valuable improvement process by participants, but the high cost and reliance on ongoing volunteerism makes its sustainability uncertain. Next steps may include exploring remote assessment strategies or direct payments, although these strategies risk reducing the acceptability, and therefore uptake, of the assessment.

Assessing Implementation Strategy Reporting in the Mental Health Literature: A Narrative Review

Inadequate implementation strategy reporting restricts research synthesis and replicability. We explored the implementation strategy reporting quality of a sample of mental health articles using Proctor et al.'s (Implement Sci 8:139, 2013) reporting recommendations. We conducted a narrative review to generate the sample of articles and assigned a reporting quality score to each article. The mean article reporting score was 54% (range 17-100%). The most reported domains were: name (100%), action (82%), target (80%), and actor (67%). The least reported domains included definition (6%), temporality (26%), justification (34%), and outcome (37%). We discuss limitations and provide recommendations to improve reporting.

Où en sommes-nous? An Overview of Successes and Challenges after 30 Years of Early Intervention Services for Psychosis in Quebec: Où en sommes-nous? Un aperçu des réussites et des problèmes après 30 ans de services d'intervention précoce pour la psychose au Québec

INTRODUCTION

Over the last 30 years, early intervention services (EIS) for first-episode psychosis (FEP) were gradually implemented in the province of Quebec. Such implementation occurred without provincial standards/guidelines and policy commitment to EIS until 2017. Although the literature highlights essential elements for EIS, studies conducted elsewhere reveal that important EIS components are often missing. No thorough review of Quebec EIS practices has ever been conducted, a gap we sought to address.

METHODS

Adopting a cross-sectional descriptive study design, an online survey was distributed to 18 EIS that existed in Quebec in 2016 to collect data on clinical, administrative, training, and research variables. Survey responses were compared with existing EIS service delivery recommendations.

RESULTS

Half of Quebec's population had access to EIS, with some regions having no programs. Most programs adhered to essential components of EIS. However, divergence from expert recommendations occurred with respect to variables such as open referral processes and patient-clinician ratio. Nonurban EIS encountered additional challenges related to their geography and lower population densities, which impacted their team size/composition and intensity of follow-up.

CONCLUSIONS

Most Quebec EIS offer adequate services but lack resources and organizational support to adhere to some core components. Recently, the provincial government has created EIS guidelines, invested in the development of new programs and offered implementation support from the National Centre of Excellence in Mental Health. These changes, along with continued mentoring and networking of clinicians and researchers, can help all Quebec EIS to attain and maintain recommended quality standards.

Early Psychosis Intervention-Spreading Evidence-based Treatment (EPI-SET): protocol for an effectiveness-implementation study of a structured model of care for psychosis in youth and emerging adults

INTRODUCTION

While early psychosis intervention (EPI) has proliferated in recent years amid evidence of its effectiveness, programmes often struggle to deliver consistent, recovery-based care. NAVIGATE is a manualised model of EPI with demonstrated effectiveness consisting of four components: individualised medication management, individual resiliency training, supported employment and education and family education. We aim to implement NAVIGATE in geographically diverse EPI programmes in Ontario, Canada, evaluating implementation and its effect on fidelity to the EPI model, as well as individual-level outcomes (patient/family member-reported and interviewer-rated), system-level outcomes (captured in provincial administrative databases) and engagement of participants with lived experience.

METHODS AND ANALYSIS

This is a multisite, non-randomised pragmatic hybrid effectiveness-implementation type III mixed methods study coordinated at the Centre for Addiction and Mental Health (CAMH) in Toronto. Implementation is supported by the Provincial System Support Program, a CAMH-based programme with provincial offices across Ontario, and Extension of Community Healthcare Outcomes Ontario Mental Health at CAMH and the University of Toronto. The primary outcome is fidelity to the EPI model as measured using the First Episode Psychosis Services-Fidelity Scale. Four hundred participants in the EPI programmes will be recruited and followed using both individual-level assessments and health administrative data for 2 years following NAVIGATE initiation. People with lived experience will be engaged in all aspects of the project, including through youth and family advisory committees.

ETHICS AND DISSEMINATION

Research ethics board approval has been obtained from CAMH and institutions overseeing the local EPI programmes. Study findings will be reported in scientific journal articles and shared with key stakeholders including youth, family members, programme staff and policymakers.

TRIAL REGISTRATION NUMBER

NCT03919760; Pre-results.

Assessing Implementation Strategy Reporting in the Mental Health Literature: A Narrative Review

Inadequate implementation strategy reporting restricts research synthesis and replicability. We explored the implementation strategy reporting quality of a sample of mental health articles using Proctor et al.'s (Implement Sci 8:139, 2013) reporting recommendations. We conducted a narrative review to generate the sample of articles and assigned a reporting quality score to each article. The mean article reporting score was 54% (range 17-100%). The most reported domains were: name (100%), action (82%), target (80%), and actor (67%). The least reported domains included definition (6%), temporality (26%), justification (34%), and outcome (37%). We discuss limitations and provide recommendations to improve reporting.

Estimating the incidence of first-episode psychosis using population-based health administrative data to inform early psychosis intervention services

BACKGROUND

Discrepancies between population-based estimates of the incidence of psychotic disorder and the treated incidence reported by early psychosis intervention (EPI) programs suggest additional cases may be receiving services elsewhere in the health system. Our objective was to estimate the incidence of non-affective psychotic disorder in the catchment area of an EPI program, and compare this to EPI-treated incidence estimates.

METHODS

We constructed a retrospective cohort (1997-2015) of incident cases of non-affective psychosis aged 16-50 years in an EPI program catchment using population-based linked health administrative data. Cases were identified by either one hospitalization or two outpatient physician billings within a 12-month period with a diagnosis of non-affective psychosis. We estimated the cumulative incidence and EPI-treated incidence of non-affective psychosis using denominator data from the census. We also estimated the incidence of first-episode psychosis (people who would meet the case definition for an EPI program) using a novel approach.

RESULTS

Our case definition identified 3245 cases of incident non-affective psychosis over the 17-year period. We estimate that the incidence of first-episode non-affective psychosis in the program catchment area is 33.3 per 100 000 per year (95% CI 31.4-35.1), which is more than twice as high as the EPI-treated incidence of 18.8 per 100 000 per year (95% CI 17.4-20.3).

CONCLUSIONS

Case ascertainment strategies limited to specialized psychiatric services may substantially underestimate the incidence of non-affective psychotic disorders, relative to population-based estimates. Accurate information on the epidemiology of first-episode psychosis will enable us to more effectively resource EPI services and evaluate their coverage.

Using Fidelity Measurement to Assess Quality of Early Psychosis Intervention Services in Ontario

OBJECTIVES

The First Episode Psychosis Services Fidelity Scale (FEPS-FS) is a validated measure of program delivery in relation to international standards. This study assessed fidelity in Ontario programs and the utility of the FEPS-FS for program improvement.

METHODS

Assessments were conducted in a volunteer sample of nine early psychosis intervention (EPI) programs. Thirty components of care were each rated on a 5-point scale; a rating of 4 indicates satisfactory performance. Trained assessor teams conducted site visits, and ratings were made by consensus.

RESULTS

Program mean fidelity ratings ranged from 3.1 to 4.4 and exceeded 4 in five programs. Across the programs, item mean fidelity ratings ranged from 2.1 to 5 and exceeded 4 for 14 of 30 items.

CONCLUSIONS

The FEPS-FS captured variation in program implementation and provided a baseline for measuring change. Additions to the scale are planned to address components of the Ontario EPI standards not covered by the FEPS-FS.

Fidelity scales and performance measures to support implementation and quality assurance for first episode psychosis services

AIM

The purpose of this paper is to review fidelity and outcome measures which can be used to support broad implementation of first episode psychosis services and ensure quality of existing services. First episode psychosis services use a combination of evidence-based practices to improve the outcome of a first episode of psychosis and the early stages of schizophrenia. Now that there is an established international evidence base to show that they are effective, efforts are being made to make such services widely available as a routine part of health care.

METHODS

We provide an overview of the literature from the perspective of an expert task force that was commissioned to report to the board of the International Early Psychosis Association IEPA. First, we examined the evidence-based components that underpin first episode psychosis services and identified common elements. Next, we reviewed the availability of fidelity measures and outcome indicators, finally we reviewed how broadly these services are delivered internationally, and the barriers to ensuring broad access to quality services.

RESULTS

There is a growing consensus about the elements required to deliver effective services. Fidelity scales and performance measures are available to assess quality, access, and outcome. First episode psychosis services are variably offered in high-income countries and rarely with attention to access and quality of services. Several strategies to promote implementation are identified.

CONCLUSIONS

Fidelity scales and outcome measure are valuable resources to support widespread implementation and quality assurance for first episode psychosis services.

Disparities in Access to Early Psychosis Intervention Services: Comparison of Service Users and Nonusers in Health Administrative Data

OBJECTIVE

There is a dearth of information on people with first-episode psychosis who do not access specialized early psychosis intervention (EPI) services. We sought to estimate the proportion of incident cases of nonaffective psychosis that do not access these services and to examine factors associated with EPI admission.

METHODS

Using health administrative data, we constructed a retrospective cohort of incident cases of nonaffective psychosis in the catchment area of the Prevention and Early Intervention Program for Psychoses (PEPP) in London, Ontario, between 1997 and 2013. This cohort was linked to primary data from PEPP to identify EPI users. We used multivariate logistic regression to model sociodemographic and service factors associated with EPI admission.

RESULTS

Over 50% of suspected cases of nonaffective psychosis did not have contact with EPI services for screening or admission. EPI users were significantly younger, more likely to be male (odds ratio [OR] 1.58; 95% confidence interval [CI] 1.24 to 2.01), and less likely to live in areas of socioeconomic deprivation (OR 0.51; 95% CI 0.36 to 0.73). EPI users also had higher odds of psychiatrist involvement at the index diagnosis (OR 7.35; 95% CI 5.43 to 10.00), had lower odds of receiving the index diagnosis in an outpatient setting (OR 0.50; 95% CI 0.38 to 0.65), and had lower odds of prior alcohol-related (OR 0.42; 95% CI 0.28 to 0.63) and substance-related (OR 0.68; 95% CI 0.50 to 0.93) disorders.

CONCLUSIONS

We need a greater consideration of patients with first-episode psychosis who are not accessing EPI services. Our findings suggest that this group is sizable, and there may be sociodemographic and clinical disparities in access. Nonpsychiatric health professionals could be targeted with interventions aimed at increasing detection and referral rates.

Implementation and development of early intervention in psychosis services in Italy: a national survey promoted by the Associazione Italiana Interventi Precoci nelle Psicosi

AIM

This is the first comprehensive, nationwide survey aimed at collecting evidence about the process of implementation and development of early intervention in psychosis (EIP) services (EIPs) in Italy, following the establishment of the pilot program 'Programma 2000' in 1999 and the publishing of the Italian National Guidelines in 2007. This survey covers all the Departments of Mental Health (DMHs) operating in Italy in 2013.

METHODS

Using a purpose-designed form to assess EIP implementation, all directors of public mental health services for adults throughout Italy (n = 216) were asked to provide information about the activities of EIP-relevant local services. The initial delivery was followed by a request for a prompt response.

RESULTS

Out of 216 enquired DMHs, 103 provided computable answers to the survey (response rate = 48%). Among responders, 45 (44%) reported the implementation of EIP (one out of five DMHs operating in Italy). About a half of the active EIPs also targeted patients at ultra-high risk of psychosis (n = 27). Strict application of guidelines related to drug prescription was reported in 35% of EIPs. Conversely, 90% provided some kind of structured psychotherapy and psychoeducation. Among EIPs, a minority reported willingness to provide initial assessment/contact at the patient's home.

CONCLUSION

Albeit slowly, the implementation of EIP is spreading throughout the Italian public network of mental health. There is still a wide variability in the distribution of EIP services across the Italian territory. Further efforts are necessary to stimulate policy endorsement and resource allocation, as well as to support the poorest zones.

A Survey of Health Equity Practices in Early Psychosis Intervention Programs: A Starting Point for Improvement

Equity has been identified as a core component of quality healthcare in Ontario. However, translating policy into practice can be challenging. This paper reports results from a province-wide survey of early psychosis intervention programs to assess the extent to which equity has been incorporated into program delivery. All 56 programs (100%) completed the survey. Results found that while most programs perceive that they are meeting equity aims, they reported limited use of practices to support this aim, and few systematically collect information on performance. Strategies to improve equity in practice are discussed.