Outreach and support in south London (OASIS): implementation of a clinical service for prodromal psychosis and the at risk mental state

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1 European Psychiatry 20 (2005) Original article Outreach and support in south London (OASIS): implementation of a clinical service for prodromal psychosis and the at risk mental state Matthew R. Broome a, *, James B. Woolley a, Louise C. Johns a, Lucia R. Valmaggia a,b, Paul Tabraham a, Rafael Gafoor a, Elvira Bramon a, Philip K. McGuire a a OASIS, PO 67, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK b Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands Received 15 June 2004; received in revised form 2 February 2005; accepted 7 March 2005 Available online 13 April 2005 Abstract Background. While recent research points to the potential benefits of clinical intervention before the first episode of psychosis, the logistical feasibility of this is unclear. Aims. To assess the feasibility of providing a clinical service for people with prodromal symptoms in an inner city area where engagement with mental health services is generally poor. Method. Following a period of liaison with local agencies to promote the service, referrals were assessed and managed in a primary care setting. Activity of the service was audited over 30 months. Results. People with prodromal symptoms were referred by a range of community agencies and seen at their local primary care physician practice. Over 30 months, 180 clients were referred; 58 (32.2%) met criteria for an at risk mental state, most of whom (67.2%) had attenuated psychotic symptoms. Almost 30% were excluded due to current or previous psychotic illness, of which two-thirds were in the first episode of psychosis. The socio-demographic composition of the at risk group reflected that of the local population, with an over-representation of clients from an ethnic minority. Over 90% of suitable clients remained engaged with the service after 1 year. Conclusion. It is feasible to provide a clinical service for people with prodromal symptoms in a deprived inner city area with a large ethnic minority population Elsevier SAS. All rights reserved. Keywords: Prodromal; Psychosis; Clinical; Service; Risk; OASIS 1. Introduction Recent evidence suggests that intervention in the prodromal phase that precedes the first episode of psychosis may be beneficial. Treatment may ameliorate prodromal symptoms such as attenuated psychotic phenomena [20]. Secondly, if individuals subsequently develop psychosis, the delay before treatment (duration of untreated psychosis; DUP) can be reduced, which may improve long-term outcome [5]. Finally, treatment may abort or defer the onset of psychosis [12,14]. However, there are concerns about the feasibility and the * Corresponding author. Tel.: ; fax: address: m.broome@iop.kcl.ac.uk (M.R. Broome). ethics of intervention at this stage. The prodrome can be difficult to identify as the symptoms and signs are subtle and relatively non-specific [12,13,21]. Moreover, potential clients may be difficult to engage if the local population has a poor relationship with mental health services or is socioeconomically deprived [3,1]. Yet it is in these communities that the incidence of psychosis is highest [9,2,7] and intervention may be most valuable. 2. Aims To assess the feasibility of running a clinical service for people with prodromal symptoms of psychosis in a deprived inner city area with a large ethnic minority population and a high incidence of psychosis /$ - see front matter 2005 Elsevier SAS. All rights reserved. doi: /j.eurpsy

2 M.R. Broome et al. / European Psychiatry 20 (2005) Methods 3.1. Catchment area The service was designed to cater for clients in Lambeth and most of the data reflect activity in this borough. Referrals were also accepted from the other boroughs served by the South London and Maudsley (SLaM) NHS Trust: Southwark, Croydon, and Lewisham. An age range of was chosen to be consistent with that employed by the PACE clinic [21] and recommended in the UK National Service Framework for schizophrenia [19]. Lambeth has a population of 275,800 of which 34% are from ethnic minorities [18], and has the highest proportion of African Caribbean residents in London. The rate of unemployment is high (8.4%) [11], with almost half being long-term unemployed (6 months or longer). The proportions of single person households (54%), homelessness and refugees and asylum seekers (~11,000) [11] are also high. Lambeth has three wards in the top 10% most deprived wards in the UK and 16 (almost three quarter of all wards) in the top 20%. The local incidence of psychosis is approximately four times the UK average [9], with the incidence especially increased in ethnic minority groups [2,7]. The local prevalence of the at risk mental state (ARMS) or prodromal symptomatology is unknown, but if it is correlated with the incidence of psychosis, it is likely to be comparably high Referrals Consultation and liaison with potential sources of referral Many health care professionals are unfamiliar with the concept of the prodrome or ARMS [16]. Initial work involved a programme of liaison with local health and non-health agencies who may encounter people with prodromal symptoms suggestive of an ARMS. These included general practitioners/primary care physicians (GP s), primary care counsellors and psychiatric nurses, college and university counsellors, community mental health teams as well as child and adolescent services. Acute and out of hours psychiatric services were also contacted. Contact involved informal meetings, presentations and the distribution of information materials. All of the 50 primary care practises in Lambeth had both written information and telephone contact, and over twothirds of the practises took part in at least one face-to-face teaching session. Information was also posted on a website ( and distributed in leaflets and newsletters. Mental health charities and voluntary organisations were also informed about OASIS. Such work has continued since OASIS began: there is an ongoing process of liaison and education will local pastoral, health and educational services Referral process Referrals were accepted by telephone, fax, letter, or and could be made by clients friends and relatives as well as health professionals. The referrer was contacted by telephone to make a preliminary assessment of the suitability of the referral. Such screening focussed around the inclusion criteria of the service (age, address of client) as well as discussion of any prior psychiatric contact of the client. An assessment was then offered, either at the client s general practice or their home, usually comprising two 1-h sessions. A psychiatrist and a clinical psychologist typically assessed clients together Assessment measures The term ARMS refers to a clinical syndrome regarded as a risk factor for subsequent psychosis [21]. An individual can meet criteria for the ARMS in one or more of three ways. 1) A recent decline in function coupled with either schizotypal personality disorder or a first degree relative with psychosis. 2) Attenuated positive psychotic symptoms. 3) A brief psychotic episode of less than 1 weeks duration that resolves without antipsychotic medication (Brief Limited Intermittent Psychosis or BLIP). The presence of the ARMS was determined via a detailed clinical assessment using the comprehensive assessment of the at risk mental state (CAARMS) [17]. Family history was examined using the family interview for genetic studies (FIGS) [15]. All participants fulfilling ARMS criteria underwent a detailed clinical assessment. The SCID-1 and SCID-2 [8] were used both to assess the presence of a schizotypal personality disorder as well as to confirm/exclude any co-morbid diagnoses. Quantitative measures of psychopathology were further obtained upon entry using the following instruments: Hamilton depression and anxiety scale and PANSS. 4. Results Over 30 months OASIS received 180 referrals. Of these, 157 were offered an assessment, 23 having been screened out due to living outside of the boroughs served by SLaM NHS Trust, being outside of the age range of the service, or after discussion with the referrer. Of these 157 suitable referrals, 19 clients either refused an assessment or recurrently failed to meet with the team. Of the 138 assessments carried out by OASIS over 30 months, 58 (32.2% of all referrals, 42% of assessments) met criteria for the ARMS Socio-demographic characteristics of ARMS clients The mean age of ARMS clients was 24 years and twothird were male (Table 1). Subjects came from all social classes and most were working, either in full-time employment or as a student. A high proportion (62.1%) were from ethnic minorities and most were not in a long-term relationship (86.2%) (Table 1) Referral sources and pathways to care Most (29.3%) clients with an ARMS were referred from primary care (GPs, counsellors or psychiatric nurses attached

3 374 M.R. Broome et al. / European Psychiatry 20 (2005) Table 1 Demographic characteristics of OASIS referrals All referrals ARMS subjects N Age in years (S.D.) 24.3 (S.D. 6.1) 24.1 (S.D ) Sex (%male) Place of birth (%) United Kingdom Africa Europe (outside UK) Caribbean Middle East South America Ethnicity (%) White British Caribbean and African Black British Other white Mixed Asian Oriental Middle East Asian Indian Employment (%) Student Unemployed Employed Marital status (%) Never married Married/living with partner Separated/divorced to the practice), the local first episode psychosis service (Lambeth Early Onset services) (27.6%), and from general adult and adolescent mental health services (27.5%). Other referrers included emergency clinic (5.2%), relatives (3.4%), school counsellors (1.7%), and self-referral (5.2%). Of the 58 ARMS clients, three referred themselves or were referred by their relatives 13 (22.3%) had only seen one other health service professional before being referred to OASIS (10 GP, one student counsellor, one Maudsley emergency clinic, one primary care counsellor). Forty-two (72.4%) had more than one previous healthcare professional contact, the breakdown of which is shown in Table Diagnoses and symptoms 32.2% of all referrals met criteria for the ARMS. Despite an emphasis on the distinction between the ARMS and psychosis in the information provided to referrers, subjects in the first episode of psychosis were common, comprising 18.3% of all referrals, and 21% of all those assessed. In most cases these were individuals in the early stages of psychosis, when the severity of symptoms was such that a diagnosis of psychosis was not immediately obvious. The remaining referrals met criteria for a range of other psychiatric disorders, including depression, and anxiety disorders (Fig. 1). Almost all those referred met DSM-IV diagnostic criteria for some disorder; all those who did not meet ARMS criteria had an alternate DSM-IV diagnosis. Attenuated psychotic symptoms were by far the commonest feature of the ARMS, being evident in 39 (67.2%) of those meeting the PACE criteria (Fig. 2). Among those with an ARMS, 56.8% (33 clients) had additional psychiatric morbidity in addition to their ARMS symptoms (Fig. 1). Of all the clients with an ARMS, there was only one case of serious self harm but there were no completed suicides or acts of violence. Of those who remain with the ARMS (not having made transition to psychosis), none have required either voluntary or compulsory admission. Table 2 Pathways to care for subjects with potential ARMS in South London Number of services consulted by client before OASIS Of all 180 referrals received (data for 172) Of 58 referrals with ARMS Self or relative 13 (7.2) 3 (5.2%) One service 50 (27.8%) 13 (22.3%) Two services 53 (29.4%) 20 (34.5%) Three services 32 (17.8%) 12 (34.5%) Four services 11 (6.1%) 3 (5.2%) Five or more services 13 (7.2%) 7 (12.1%) Fig. 1. Diagnosis at assessment (ARMS = at risk mental state).

4 M.R. Broome et al. / European Psychiatry 20 (2005) OASIS. Of the 53 who were followed up, six later developed psychosis, five dropped out of follow up after 6 months because they did not wish further contact or failed to attend appointments, and six moved out the catchment area and were transferred to other services. Clients and their relatives were generally happy with the service offered by OASIS, particularly with clinical contact being outside traditional mental health settings and that the staff were flexible about the timing of appointments. Primary care clinicians liked having clients seen in their surgery and the accessibility of the service. 5. Discussion 5.1. Recruitment of clients with an ARMS Fig. 2. Subgroups of ARMS (total number of clients = 58) Treatment The present study was not designed to formally evaluate the effectiveness of treatment. Clients were provided with an intervention package that included social support, symptom monitoring plus cognitive behaviour therapy, antidepressant and antipsychotic medication, depending on the presentation and the client s preferences. At the time of entry to the service, none of the clients had been prescribed antipsychotics by their referrer or other health professional. Subsequent to entry to OASIS, 23 clients (39.7%) received a combination of medication (SSRI or low dose atypical neuroleptic) together with psychological treatment (CBT or supportive psychotherapy), 18 (31%) received only psychological intervention and three clients (5.2%) received only medication. All these treatments were well tolerated and practicable. Most clients were keen to receive treatment. Some were reluctant to take medication, sometimes because they wanted to see if they could manage with psychological input alone. Others specifically requested medication, often because they sought rapid relief from distressing symptoms. The issue of stigmatisation was not raised by any of the clients, and none felt that they had been stigmatised through their contact with the service Transition to psychosis Six clients who met ARMS criteria subsequently developed a first episode of psychosis. Five were male, and one female with an average age of 25.4 years. In these individuals the mean delay between the onset of frank psychosis and the initiation of treatment for psychosis was 12 days (range 7 21). Four of these clients (66.7%) required admission and one case (16.7%) involved assessment for compulsory admission under the UK Mental Health Act Engagement and user satisfaction Five clients with the ARMS preferred to be followed-up by their referring clinician (usually their GP) rather than OASIS received 180 referrals over the first 30 months, of whom 58 met criteria for the ARMS. This is broadly comparable with data from the PACE clinic in Melbourne, which received 162 referrals in its first 20 months, of whom 49 met criteria [16], despite OASIS operating in area which is more socio-economically deprived, has a larger ethnic minority population and a more difficult relationship between service users and mental health services. The difference in the total number of referrals may reflect multiple factors but a critical one may have been the presence in Melbourne (but not London) of an additional Early Psychosis Assessment and Crisis Team (EPCAT) which accounted for 45% of the PACE referrals [16]. The latter, plus better integration between adult and adolescent services for psychosis, may also have contributed to the younger age of PACE compared to OASIS clients (18 years in Melbourne as opposed to 24 years of age in London). The gender distribution of clients in both services was similar, with an excess of males. There was an average of 2.34 prior contacts (such as GP, private psychiatrist, counsellor) before assessment, comparable to a figure of 2.36 from PACE [16]. This suggests that OASIS clients were actively seeking help, with most having already consulted primary care and one other health professional before referral. Thirty-two percent of all referrals met ARMS criteria. Thus, approximately 2.4 assessments were required per ARMS case identified. The proportion of referrals which met criteria was higher than expected, but is comparable to the 33% figure from the PACE clinic. This may both reflect the high prevalence and incidence of psychosis in South London, which if continuum models of psychosis are correct, may impact upon the epidemiology of the ARMS. In addition to those with an ARMS, a further 20% of referrals were experiencing a first episode of psychosis and almost 10% had a prior history of psychotic illness. Thus, in addition to detecting cases at high risk of developing psychosis, OASIS supplemented additional mental health services in being able to detect established psychotic illness, particularly the first episode. As OASIS had good links with the local first episode psychosis service [4], cases with psychosis could

5 376 M.R. Broome et al. / European Psychiatry 20 (2005) readily access appropriate treatment with a seamless continuity of care. Almost 65% of referrals had either an ARMS or a psychotic illness, suggesting that services like OASIS can significantly facilitate implementation of national guidelines, such as the UK National Service Framework for schizophrenia. This suggests that although most referrers were not mental health professionals, a high proportion of referrals were appropriate for the service. This may reflect the impact of the educational work carried out by OASIS but also indicates that clinicians with no specialist training in this area are able to identify people with the ARMS Ethnicity Almost two-thirds of referrals of the ARMS cohort came from ethnic minorities and over 20% were born outside of the UK (Table 1). Although the age and social class of those referred was broadly comparable to that of the local population, a high proportion of our clients were from ethnic minorities: 64% as opposed to 34% of the local population. As can be seen in Table 1, the definition of ethnic minority was broad and included everyone who described themselves other than white British. This over-representation of people from ethnic minorities is also evident locally among patients with first episode psychosis [4,7], and is consistent with evidence that environmental factors that are associated with psychotic disorders (such as discrimination) are also associated with psychotic symptoms [10] also demonstrates that services for people with prodromal symptoms are able to engage clients from ethnic minority populations. This is a key objective of mental health services in the UK, as the latter are especially at risk of psychosis but their engagement with conventional services is relatively poor. Initiating contact before symptoms become severe and the client is in crisis may facilitate engagement in these groups Presenting symptoms and clinical characteristics Most OASIS clients experienced attenuated symptoms, either alone or in combination with one of the other inclusion criteria. Only 12.1% of clients met criteria purely due to a BLIP, and 1.7% for state and trait factors (a decline in function coupled with a schizotypal personality disorder or a family history of a first degree relative with a psychotic illness). This is consistent with the distribution of symptoms in clients of the PACE clinic, who mainly had attenuated symptoms, although they were more likely to have them in combination with other diagnostic features [21] these differences may reflect the fact that referrers in the UK find it easier to identify attenuated symptoms than the other criteria, and that these symptoms are more likely to enable the client to access health care or consider seeking help. Those who present to health services may not be representative of the total ARMS population and thus the distribution of symptoms in our sample may not reflect that of the ARMS population as a whole. The age of subjects with the ARMS was lower than that of those with a first episode of psychosis in the same area [4], who had a mean age of 26 years. The concept of the ARMS remains somewhat controversial, but even if the symptoms that contribute to the presence of the ARMS are excluded, over 55% of the ARMS group had additional psychiatric morbidity (see Fig. 1). All of the referrals who were not categorised as ARMS met criteria for a psychiatric disorder as defined by DSM-IV. Thus, independent of the validity of the ARMS, most of those referred to OASIS had unmet mental health needs which were causing them distress and disability. Referrers of those who did not have an ARMS were provided with a detailed assessment, advice on management and the offer of liasing with alternate services that could provide clinical care for the client. This was appreciated by both clients and referrers Transition to psychosis Six clients developed psychosis while being managed by OASIS. Because they had already been engaged and were regularly monitored for signs of frank psychosis, the delay before they were referred for treatment of frank psychosis was much shorter than is typical in the UK (12 days as opposed to 10.5 months). While the present study cannot assess the long-term outcome in these cases, there is evidence that a shorter DUP is associated with improved prognosis [6]. Of the six clients who developed psychosis, only one required compulsory assessment, which is lower than among patients presenting with a first episode of psychosis locally [4], and our overall clinical impression was that their management was generally easier and less traumatic. However, the question of whether engagement in the prodromal phase improves long-term outcome in psychosis needs to be examined in controlled trials with larger numbers of subjects Logistical demands Because clinical contact was usually at each client s general practice, management involved a great deal of travel for the clinicians, with journeys of up to 1 h each way. Moreover, the assessments usually involved two clinicians and were detailed, taking place over two 1-h sessions. The clinicians involved were typically a psychiatrist and clinical psychologist and the assessment included, wherever possible, a detailed collateral history. At the time of its inception, the service consisted of one part-time consultant psychiatrist, one part-time psychiatrist in training, and one part-time clinical psychologist. During the period detailed, more staff joined the service including a full-time clinical psychologist, two further parttime psychiatrists in training, a team leader, and a part-time team administrator. After the assessment, clients were seen weekly to fortnightly for the first 1 2 months, and subsequently for a period of 2 years at a frequency determined by clinical need. The above approach thus placed considerable

6 M.R. Broome et al. / European Psychiatry 20 (2005) logistical demands on the service. However, it was popular with both clients and referrers and much of the work could be planned and organised in advance: there were relatively few crises that required urgent clinical contact. The assessment itself was a further opportunity to liase and train our referrers: frequently the clinicians could meet and discuss the case with the referrer both prior to and immediately after the assessment having taken place The future of OASIS As mentioned above, a formal trial is now underway with the client in our service to assess the acceptability and efficacy of intervention in the at-risk group. The aims of such a study will be to determine whether intervention not only can improve DUP and the prognosis of psychotic illness once established, but also whether intervention may abort or defer the transition to frank psychosis. The clients in our service are characterised by good engagement and an active desire to take part in research: thus, in addition to taking part in evaluation of the service and the treatments OASIS offer, clients also have been taking part in neuropsychology, cognitive psychology, imaging, and neurophysiology research. Further, a formal economic analysis of OASIS in terms of cost: benefit to the United Kingdom National Health Service is currently being carried out. Clinical Implications: It is possible to identify and manage people with an ARMS for psychosis, even in a deprived inner city area with a high proportion of people from ethnic minorities. All referrals were help-seeking, distressed and would otherwise have had difficulty accessing mental health services. Services for people with prodromal symptoms complement first episode psychosis services and help meet the objectives of the United Kingdom National Service Framework for schizophrenia. Limitations of the study: Those referred to the service may not represent the population of people with prodromal symptoms as a whole. Although the prodrome was defined using the most widely employed criteria, the findings may have differed had other diagnostic criteria been used. The study was not designed to evaluate the effectiveness of treatment in this group. Acknowledgements Dr. Mark Ashworth helped set up the service. Ms. Corinne Prescott and Mrs. Sandra Whitehead provided administrative support. Professor Philippa Garety and Professor Elizabeth Kuipers supervised the clinicians providing psychological treatment. The study was supported by the Mental Health Foundation and Guy s and St Thomas Charitable Foundation. Dr. Elvira Bramon is a Wellcome Research Training Fellow. Thanks go to all the clients in OASIS and our referrers, especially the Lambeth Early Onset (LEO) psychosis service. References [1] Bhui K, Stansfeld S, Hull S, Priebe S, Mole F, Feder G. 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