East Asian Arch Psychiatry 2012;22:114-7

THEME PAPER

新加坡思觉失调早期干预服务的演变

Dr Swapna Verma, MBBS, MD, Department of Early Psychosis Intervention, Institute of Mental Health, Singapore.
Ms Lye-Yin Poon, BSocSci, Department of Early Psychosis Intervention, Institute of Mental Health, Singapore.
Ms Helen Lee, Grad Dip, MA, Department of Early Psychosis Intervention, Institute of Mental Health, Singapore.
Dr Sujatha Rao, MBBS, MRCPsych, Department of Early Psychosis Intervention, Institute of Mental Health, Singapore.
Dr Siow-Ann Chong, MBBS, MMed, MD, FAMS, Institute of Mental Health, Singapore.

Address for correspondence: Dr Swapna Verma, Department of Early Psychosis Intervention, Institute of Mental Health, 10 Buangkok View, Singapore 539747.
Tel: (65) 6389 2000; Fax: (65) 6389 2963; email: Swapna_VERMA@imh.com.sg

Submitted: 29 February 2012; Accepted: 30 July 2012

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Introduction

In the late 1980s, a movement for early intervention of psychosis led by Professor Patrick McGorry was started in Melbourne, Australia. The Early Psychosis Prevention and Intervention Centre was set up in view of the high costs and extensive disability associated with psychosis. Considering the evidence showing an association between shorter duration of untreated psychosis (DUP) — the time between the first onset of psychotic symptoms and first adequate treatment^1,2 — and a faster, better treatment response, the clinical service was provided with an aim to reduce the DUP.

Early Psychosis Intervention Programme

A study of Singaporean patients with first-episode psychosis (FEP) found that the DUP ranged from 0.1 to 336 months, with a mean of 32.6 months and a median of 12 months.³ This alarmingly long DUP and the potential harm associated with it were the driving force behind the establishment of Singapore’s national Early Psychosis Intervention Programme (EPIP) in April 2001. The programme, led by a multidisciplinary team consisting of psychiatrists, psychologists, case managers, social workers, nurses, and occupational therapists, is designed to provide comprehensive, integrated, and patient-centred services. The EPIP aims to: (1) raise public awareness of psychosis and reduce the stigma associated with the condition; (2) establish collaborations with primary health care providers to enhance the detection, referral, and management of individuals with psychosis; and (3) improve patient outcomes and relieve caregivers’ burden.⁴

In order to achieve these aims, we embarked on a number of community outreach programmes, including media involvement with radio shows, TV documentary dramas, newspapers, and magazines, publication of an easy- to-read book on psychosis, posters placed in train stations, public forums, art exhibitions, and a website (www.epip.org. sg). Initiatives were also launched with the aim of educating, networking, and collaborating with primary health care providers (private and polyclinic general practitioners, counsellors from the various tertiary institutions, social and welfare services, and traditional healers). We also streamlined the referral process so that primary health care providers could refer patients with suspected FEP to our clinical service as seamlessly as possible.

The programme was soon proven effective—within 2 years after the introduction of public awareness campaigns and the intensive community outreach service, the median DUP has dropped from 12 months to 4 months; a positive shift was also observed in the referral pattern, with a 15% reduction in police referrals and a shift towards self, family, and primary care referrals.⁵

The clinical service provides phase-specific multi- disciplinary care to all patients with FEP aged between 16 and 40 years, who are followed up for a period of 2 years.

Case Management Model in Early Psychosis Intervention Programme

The role of the case managers in delivering care has been crucial, and forms the linchpin of the clinical services. The case managers are allied health professionals who come from specialised educational backgrounds of psychology, social work, or nursing. Similar to other early intervention programmes worldwide, we combine the brokerage and therapeutic models. Delivering psycho-education, coordinating resources, and providing supportive counselling are the general duties of the case managers. Intervention is customised according to each patient’s needs and the phase of recovery. We categorise recovery phases into acute, stabilisation, stable, discharge from the programme, and termination. Some of the general tasks and goals that case managers are expected to perform are listed in the Table.

Outcomes and Indicators

The EPIP was included in the first-ever National Mental Health Blueprint⁶ in Singapore in April 2007. The Blueprint was developed by the Singapore Ministry of Health (MOH) and stakeholders, with an aim to promote mental health, prevent development of mental health disorders, and reduce the impact of mental health disorders where possible.⁴

Programmes under the Blueprint are regularly evaluated to be accountable to the stakeholders, based on performance indicators established a priori. These indicators are mutually set by the individual programme directors and the MOH and incorporate a myriad of structure, process, and outcome measures to offer a multi-dimensional evaluation of the programmes. As such the following outcome indicators were set for the EPIP⁴:

• number of patients screened and accepted into the EPIP;
• proportion of patients showing symptom improvement at the end of 2 years;
• proportion of patients showing improved functioning level at the end of 2 years;
• levels of patient satisfaction with the EPIP service;
• proportion of patients remaining engaged with the EPIP;
• suicide rate within 2 years of diagnosis.

Data Analysis

Patients enrolled in the EPIP service since April 2007 were included. Inclusion criteria were: aged 16 to 40 years; first- episode psychotic disorder; and psychosis not secondary to substance abuse or medical conditions. Patients accepted into the EPIP are followed up for a period of 2 years before being discharged to downstream services.

Evaluation of the EPIP was done through a component of regular clinical assessments and by analysing operational statistics generated from the hospital database.⁴ Severity of psychopathology was assessed by the Positive and Negative Syndrome Scale (PANSS)⁷ for schizophrenia, and the Global Assessment of Functioning (GAF)⁸ was used to assess the level of functioning at regular intervals. Also, patients were asked to rate their satisfaction with the service provided by the EPIP on the Client Satisfaction Questionnaire (CSQ- 8).⁹

A total of 1293 individuals were screened and 815 accepted into the EPIP between April 2007 and March 2011 201 Among them, 8 (1%) were having at-risk mental state (ARMS) and 12 (1.5%) had missing data. Baseline analysis was carried out in the remaining patients (n=795). There were 404 (51%) males. As one patient who would be turning 41, and 3 patients who would be turning 16 in that calendar year were also accepted for this study, the mean (± standard deviation) age of the sample was 27 (± 7) years (range, 15-41 years).² Of these 795 patients, 51 patients were discharged early because they moved out of the country or wished for follow-up by a private psychiatrist; 6 patients had completed suicides. In all, 470 patients (59%) completed 2 years of follow-up with the programme while the rest are still on follow-up with the EPIP. Complete data for the PANSS and GAF assessments both at baseline and 2-year assessments were available for 284 patients.

At the end of 2 years, 85% (241 / 284) of the patients scored ≥ 61 on the GAF disability, and 66% (188 / 284) met criteria for functional remission, which was defined as having a GAF disability score of ≥ 61 with engagement in age-appropriate vocation (gainfully employed or studying) at 2 years. There was also a significant decrease in the PANSS for schizophrenia (t = 27.7, p < 0.05) and increase in GAF (t = 33.7, p < 0.05) mean scores from baseline at 2 years.

Among the 197 patients who completed the CSQ-8, 187 (95%) gave a rating of “good” or higher for the EPIP service at the end of 2 years.² Of those 470 patients who completed 2 years of follow-up, 66% (n = 310) were either in face-to-face or telephone contact. Those 6 patients who committed suicide within 2 years of diagnosis gave a suicide rate of 1.3% (6/470).

Discussion

As shown in the clinical outcome measures including treatment response and recovery, level of service satisfaction and default rate, EPIP has proven to be a clinical service of high quality. The number of patients served under the programme has increased steadily since its launch, as a result of the active outreach and networking efforts of the EPIP. Importantly, a suicide rate close to 1% was achieved, meeting the target set in the international consensus statement on early psychosis.^2,10

It should be pointed out that the missing data from patients who had completely disengaged from the programme or opted not to provide certain information might be a limitation of our current analysis. Future studies with adequate data for cost-effectiveness analysis would also help further improve the service design.²

Support for Wellness Achievement Programme

Early identification and intervention for individuals with ARMS may prevent the development of a full-blown psychotic disorder.¹¹ Together with the impetus and funding provided with the National Mental Health Blueprint, an initiative to further promote mental health by targeting the ARMS was made possible in 2008. The Support of Wellness Achievement Programme (SWAP), launched in March that year, is a clinical service provided for individuals aged between 16 and 30 years presenting with ARMS.²

Phillips et al¹² have defined an operational set of clinical features that can be used to identify individuals presenting with ARMS. These criteria have been adopted by SWAP. The clinical features are a combination of state and trait factors. The Comprehensive Assessment of At-Risk Mental States (CAARMS), a semi-structured questionnaire developed by Yung et al,¹³ encompasses the above-mentioned criteria and is employed to assess individuals to elicit a diagnosis of ARMS. Acceptance into the SWAP service is based on clinical judgement assisted by the CAARMS, which is administered by case managers who have received training in the use of this instrument.

Once individuals are accepted into the programme, they are followed up for a minimum period of 2 years. The SWAP uses a multi-disciplinary team approach and management is targeted at the individuals using a biopsychosocial model of care. Psychotropic medications are prescribed for any existing co-morbid disorders if deemed necessary. However, antipsychotic medication is not routinely prescribed for individuals with ARMS unless they are extremely distressed by the attenuated symptoms or if they request medication. In such individuals, a low dose of antipsychotic is prescribed.

Community Health Assessment Team

In a continuing attempt to encourage young people in Singapore to seek early help for any mental health issues and not just for psychosis, barriers to seeking early help were identified. These include a gap in the provision of mental health assessment services for young people in post- secondary education, the stigma of seeking assessment, and cumbersome referral processes.

Under the funding of the MOH in Singapore, the EPIP launched the Community Health Assessment Team programme in April 2009, which aims to promote awareness of youth mental health issues, to increase accessibility to and encourage use of mental health services by young people, and to streamline the referral process for young people to access mental health services.

Future Challenges

We have shown that a strategy, which combines a universal approach to raising awareness among the general population and a narrower approach targeting the vulnerable population (late adolescent and early adult groups), coupled with an early detection system (collaborating with primary health care providers, having a youth-centric focus, and outreach through social media), is feasible. The future challenges will be to consolidate what we have achieved and push forward to improve further on our services. Sustainability has to be attained through the incorporation of the concept of early detection and intervention as an objective of policy formulation and, hence, is worthy of long-term funding.

References

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