International application of standards for health care quality, access and evaluation of services for early intervention in psychotic disorders

Implementation of early intervention clinical services within the National Health System in Italy: Third wave survey with focus on structures, resources, and fidelity to the evidence-based model

BACKGROUND

Early intervention in psychosis (EIP) is a well-established approach aimed at detecting and treating early signs and symptoms of psychosis to prevent its long-term consequences. The present study aimed at detailing the current status of EIP services in Italy, covering all the Departments of Mental Health (DMHs) operating in 2018.

METHODS

All directors of public DMHs operating in Italy in 2018 (n = 127) were invited to fill in a Census form about EIP structure and activities. The first episode psychosis services fidelity scale (FEPS-FS) was used to investigate fidelity to the EIP model of the centre.

RESULTS

An active EIP service was reported by 41 DMHs (32% of the total DMHs; 56% of those who took part in the survey). Most EIP services had an autonomous team. The large majority of the Italian EIP centres provided psychosocial interventions to their patients, principally psychotherapy, family support, and psychoeducation. Among those with an active EIP, 29 DMHs filled in the FEPS-FS. Internal consistency was good when based on the replies of the respondents, but reliability was weak when measured on the basis of an independent evaluation (Cohen's kappa = 0.571). The fidelity to the guidelines for early intervention was uneven, with some criteria met by most centres, especially those peculiar to the Italian community psychiatry.

CONCLUSION

A further spreading of the early intervention model across the Italian DMHs was found. A lack of resources might limit the use of specific psychosocial treatments, such as cognitive-behavioural therapy or manualized family support.

The cognitive-phenomenological assessment of delusions and hallucinations at the early intervention in psychosis service stage: The results of a quality improvement project

AIM

Clinical assessments are vital for gaining an understanding of a patients' presenting problem. A priority for Early Intervention in Psychosis Service staff is understanding and supporting their patients' experiences of hallucinations and/or delusions. We aimed to identify what cognitive-phenomenology dimensions of hallucinations and delusions EIPS staff were assessing with their patients.

METHODS

We developed a brief checklist of cognitive-phenomenological dimensions of hallucinations and delusions called the Lived Experience Symptom Survey (LESS) based on relevant literature. As part of a Quality Improvement Project, we reviewed the health records of a sub-sample of EIPS patients using the LESS identifying whether each dimension was present or absent.

RESULTS

We found that all patients had been asked about the content of their hallucinations and/or delusions, and the majority had been asked about the valence of this content. Despite patients having experienced psychosis for almost 2 years on average, less than half of patients were asked about the potential or actual harm associated with these symptoms. All other cognitive-phenomenological dimensions were assessed inconsistently.

CONCLUSIONS

The assessment of hallucination and delusions in our EIPS was inconsistent and incomprehensive. These findings require replication in other EIPS' but may point to a need for guidelines and training around how to conduct a thorough assessment of hallucinations and delusions for current and future EIPS staff. Improved assessment of these symptoms will aid the development of risk assessments and treatment plans.

A comparison of the National Clinical Audit of Psychosis 2019/2020 standards and First Episode Psychosis Services Fidelity Scale 1.0

AIM

The authors compare two approaches to assessment of the quality of early psychosis intervention services, the National Clinical Audit of Psychosis used in the United Kingdom and the First Episode Psychosis Services Fidelity Scale used in North America and Europe.

METHODS

We compare the two approaches on the source of standards, measurement type, data collection, time requirements, scoring and reliability. Finally, we review their strengths and limitations.

RESULTS

Both measures are based on standards derived from the same research evidence base. Both methods rely on data from health records and administrative data. The audit is supplemented with user survey data, the fidelity scale with clinician interviews. The audit requires more time. The audit is based on quality indicators rated as present or absent which yields a statistical benchmark. The Fidelity Scale is based on quality indicators that are rated on a five-point scale yielding a standards-based measure. The two methods cover similar service components, but the FEPS-FS has a broader coverage of team functioning. The National audit also collects data on the user experience directly from patients. The fidelity scale has achieved good to excellent inter-rater reliability, the reliability of the audit has not been tested.

CONCLUSIONS

Both methods have face validity and provide reliable and useful measures of quality of care. The NCAP works in the context of a single provider health system, the FEPS-FS works in a more variable health system. Comparing the two systems in the field would support international comparison of standards of care.

Implementation case study: Multifamily group intervention in first-episode psychosis programs

AIM

Family interventions are a core component of first-episode psychosis (FEP) treatment; however, low implementation rates are consistently reported. As such, work is needed to understand the factors impacting real-world treatment delivery. The present paper describes the implementation of the McFarlane-model multifamily psychoeducational groups (MFG) in established FEP early intervention programs within a single state. The aims were to examine (a) training participation and implementation of MFG, (b) barriers and facilitators to implementation, and (c) modifications made to MFG.

METHODS

Practitioners from six established FEP early intervention programs received in-person training and ongoing consultation in MFG. Training participation data were obtained via attendance and implementation outcomes were obtained from practitioner reports. Fifteen months following the initial training, practitioners reported on clinic-specific barriers, facilitators, and modifications across four categories (context, intervention, practitioner, and recipient).

RESULTS

Twenty-three practitioners across six clinics received in-person training and were offered ongoing consultation to support implementation. Difficulties in starting MFG were salient as the earliest group was run 7 months after the initial training, thereby resulting in low overall frequency of groups. A number of barriers spanning context, intervention, practitioner, and recipient domains were noted, the majority of which were clinic-specific. Despite challenges, practitioners identified several facilitators and made modifications to the intervention and its delivery in service of implementation.

CONCLUSIONS

Results from this implementation case study highlighted the challenges of delivering MFG in real-world FEP early intervention programs. Further, this paper emphasizes the value in identifying and addressing clinic-specific factors when implementing MFG.