General Practitioners’ Knowledge of a Local First-Episode Psychosis Treatment Program
Publication: American Journal of Psychiatry Residents' Journal
Over the last three decades, early-psychosis intervention (EPI) programs have been established to identify and provide treatment to individuals experiencing a first episode of psychosis—the majority of whom are adolescents and young adults (1). EPI programs provide medical and psychosocial intervention through an intensive, multidisciplinary case management model (1, 2). Patients are followed closely over time and paired with a range of health professionals. In addition to ongoing psychiatric treatment, for example, clinic nurses monitor metabolic side effects of antipsychotic medications, and psychologists conduct cognitive-behavioral therapy with patients. Family members are offered educational and support group services, and patients attend practical, interactive programming relating to employment and social skills.
A large body of evidence now exists demonstrating the benefits of specialized EPI services to individuals experiencing psychosis for the first time, including the reduction of positive and negative symptoms; treatment of comorbid conditions such as substance abuse, anxiety, and depression; minimization of interpersonal, educational, and occupational disruptions; and improvements in overall daily functioning (2, 3). Unfortunately, individuals often present to EPI programs after a prolonged duration of untreated psychosis (4), which is associated with significantly poorer outcomes (5–7). Among other factors, prolonged duration of untreated psychosis can be due to lack of recognition of signs and symptoms among both patients and practitioners, patient reluctance and/or lack of insight into the condition, and/or inadequate access to primary care (2, 4).
One area of interest in duration of untreated psychosis reduction is the role of general practitioners in recognizing prodromal or acute signs and symptoms of psychosis and identifying appropriate pathways to care (2, 8, 9). In the Canadian health care system, general practitioners act as primary caregivers, as well as “gatekeepers,” to specialist care. Referrals to specialists, such as psychiatrists, are most frequently made by general practitioners. General practitioners often see patients and families longitudinally and are able to recognize subtle behavioral changes or the presence of new symptoms. General practitioners are thus uniquely positioned to identify prodromal signs and symptoms of early psychosis, which include a decline in academic functioning, poor hygiene and personal care, social withdrawal, decreased motivation, and impaired emotional expression (2).
The purpose of the present study was to explore general practitioners’ knowledge of a local EPI program in Kingston, Canada. Established in 2004, the Heads Up! EPI program at Hotel Dieu Hospital in Kingston is an outpatient service available to patients aged 14 to 35 who are experiencing a first episode of psychosis or who have not previously received treatment for psychosis. Patients who meet these criteria and live in the catchment areas are eligible for treatment that is more comprehensive than general outpatient treatment with general practitioners or psychiatrists. Despite the existence of this evidence-based EPI program, data collected by the clinical coordinator of the Heads Up! EPI program indicate that the program receives the majority of its referrals from inpatient and emergency department psychiatrists. Very few referrals are received from general practitioners. We were therefore interested in better understanding local general practitioners’ knowledge of the Heads Up! EPI program.
Method
A survey was mailed to 106 general practitioners practicing full- or part-time in Kingston, Canada. To generate this list, an online search was conducted to identify general practitioner practices in Kingston and the surrounding county. Each practice was contacted by the principal investigator and asked how many general practitioners were employed full- or part-time. The mailed paper-based survey consisted of 10 multiple-choice questions that were aimed to elicit general practitioners’ knowledge of the Heads Up! EPI program and their understanding of the eligibility criteria, referral process, and services offered (see Table 1). This study was approved by the ethics committee at Queen’s University in Canada.
| Have you heard of the early-psychosis intervention program at Hotel Dieu Hospital in Kingston? (yes/no) |
| Have you ever referred a patient to this program? (yes/no) |
| If so, approximately how many patients have you referred? |
| Are you aware of the eligibility criteria of the early-psychosis intervention program? (yes/no) |
| Do you know how to refer a patient to the program? (yes/no) |
| Would learning more about the early-psychosis intervention program enable you to provide better clinical care to your patients? (yes/no) |
| Do you currently have patients in your practice that you believe would benefit from the early-psychosis intervention program? (yes/no) |
| We would love to provide you with more information about our program. What would be the most effective way to give you this information?) |
| a) Information package sent to you by mail |
| b) Information package sent to you by e-mail |
| c) A presentation by one of our staff at your clinic |
| d) A presentation and tour held at our clinic |
| e) Other (please specify): _____________ |
| What information can we provide you that would be most helpful? (please check all that apply) |
| Information about the common presentations of first-episode psychosis |
| Information about the management of first-episode psychosis |
| Our program’s eligibility requirements |
| How to refer a patient to our program |
| Services offered to patients by our program |
| Other: (please write in response) __________________________ |
| If you would like us to provide you with information, please tell us the best way to get in touch with you: (write in response) __________________________ |
a
Further details can be obtained online (http://www.hoteldieu.com/programs-and-departments/early-psychosis-intervention-program).
Results
Seventy-two of the 106 general practitioners contacted responded to our survey (68% response rate). Only 45% of responding general practitioners had heard of the Heads Up! EPI program. Of those surveyed, 32% had referred a patient to the program, although 75% reported feeling that they had patients in their practice that would benefit from the program’s services. The majority (82%) were unaware of the eligibility criteria, and 79% did not know how to refer a patient. Eighty percent of the general practitioners stated that learning more about first-episode psychosis and the EPI program would enable them to provide better clinical care to their patients. One hundred percent requested to receive more information. The majority of respondents requested to receive an information package by mail (60%), whereas others preferred to receive information by e-mail (22%) or by a presentation at their practice given by an EPI staff member (18%).
Discussion
Our results indicate that while the majority of general practitioners felt that they had patients in their practice that would benefit from an EPI program, general practitioners lacked knowledge of the program, the eligibility criteria, and/or the referral process, factors that may explain the gap between the low referral rates and the perception of need. This was reinforced by the finding that the majority of general practitioners believed learning more about the EPI program would enable them to provide better clinical care to their patients, and 100% of general practitioners requested to receive more information.
It is vital that patients in need of EPI services are able to access these programs in a timely fashion (5–7). Patients with longer duration of untreated psychosis are less likely to achieve remission (5) and experience significantly poorer quality of life and overall functioning (5, 6). One study conducted in British Columbia, Canada, examined treatment delays in patients presenting to a specialized EPI program and found that patients had an average of 3.02 (SD=1.31) service contacts prior to entry into the EPI program or hospital (10). Nearly a third of patients had four or more contacts with services prior to entering the EPI program (10). Reductions in duration of untreated psychosis are thus a crucial area for improvement in the treatment of first-episode psychosis.
Our study also elucidates the need for psychiatrists to provide psychoeducation to other health care professionals. As our study indicates, general practitioners are keen to learn more about topics that they believe will benefit patients in their practice and improve their clinical care. This presents an opportunity for strengthening existing mental health care pathways and bridging gaps in referral networks. Psychiatrists, as advocates and educators, can use this research by treating encounters with general practitioners as opportunities to share knowledge about early warning signs, as well as local pathways to specialized care.
Multiple follow-up steps have been taken since the results of this research became available. Information packages on the EPI program were sent to over 300 general practitioners in the surrounding area. The EPI referral form was embedded into the electronic health records systems of multiple general practitioners’ practices, enabling them to have quick and easy access. Several presentations were given by EPI staff at general practitioner offices. EPI staff were also invited to present at the Queen’s University Grand Rounds. These are all feasible steps that can be taken elsewhere to increase general practitioners’ knowledge of local EPI programs and the signs of early psychosis.
Conclusions
Our study demonstrates that the majority of general practitioners in Kingston, Canada, were unaware of the services offered by a local EPI program. Despite this, many general practitioners stated that they had patients who would benefit from the EPI program and felt that learning more would improve the clinical care they provided. The results of our survey support calls to further educate health care professionals about EPI programs and appropriate pathways to specialized care of psychosis (2, 8, 9).
Key Points/Clinical Pearls
•
Early-psychosis intervention (EPI) programs have been established internationally to identify and provide multidisciplinary treatment specific to the needs of individuals experiencing psychosis for the first time.
•
A long duration of untreated psychosis is associated with significantly poorer clinical outcomes, for example, the presence of symptoms at follow-up, as well as with significantly poorer quality of life and overall functioning.
•
General practitioners, due to their longitudinal relationship with patients and their role as “gatekeepers” to secondary care, play a vital role in recognizing the prodromal signs and symptoms of psychosis but may lack knowledge of psychosis intervention services offered in their area.
•
The majority of general practitioners surveyed felt that they had patients in their practice that would benefit from an EPI program and believed that learning more about the EPI program would enable them to provide better clinical care to their patients.
References
1.
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2.
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3.
Nordentoft M, Rasmussen JO, Melau M, et al: How successful are first episode programs? A review of the evidence for specialized assertive early intervention. Curr Opin Psychiatry 2014; 27:167–172
4.
Lloyd-Evans B, Crosby M, Stockton S, et al: Initiatives to shorten duration of untreated psychosis: systematic review. Br J Psychiatry 2011; 198(4):256–263
5.
Marshall M, Lewis S, Lockwood A, et al: Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: A systematic review. Arch Gen Psychiatry 2005; 62(9):975–983
6.
Norman RM, Manchanda R, Windell D, et al: The role of treatment delay in predicting 5-year outcomes in an early intervention program. Psychol Med 2012; 42(2):223–233
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Perkins D, Gu H, Boteva K, et al: Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: A critical review and meta-analysis. Am J Psychiatry 2005; 162:1785–1804
8.
Flora N, Anderson KK, Ferrari M, et al: Comparative analysis of pathways to early intervention services and duration of untreated psychosis in two Canadian cities. Early Interv Psychiatry (Epub ahead of print, March 9, 2016) doi: 10.1111/eip.12326
9.
Ministry of Health and Long-Term Care, Ontario, Canada: Early Psychosis Intervention Program Standards, 2011. http://www.health.gov.on.ca/english/providers/pub/mental/epi_program_standards.pdf (Accessed September, 2016)
10.
Ehmann T, Tee A, MacEwan G, et al: Treatment delay and pathways to care in early psychosis. Early Interv Psychiatry 2014; 8:240–246
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American Journal of Psychiatry Residents' Journal
Pages: 6 - 8
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Published online: 1 September 2017
Published in print: September 01, 2017
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