REDIRECT- Evaluating the Effectiveness of an

Educational Intervention about FEP in Primary Care

Helen LesterNovember 1st 2007

Study team Max Birchwood Maria Michael Lynda Tait Nick Freemantle Amrit Khera Kate Harris Christopher John

Primary Care Policy Context

Primary care is viewed as increasingly important in mental health policy terms

Links between primary care and EI/FEP are still tenuous

Limited by incidence, knowledge and attitudes

Incidence of FEP Most GPs will see one new person with FEP

each year, and will have approximately 12 patients on their list with a diagnosis of psychosis

Similar incidence to meningococcal meningitis

Negative stereotypes still exist among GPs 

GP Attitudes“When I approached my GP, he never gave me any hope that things could change. I remember being told that I’d never be able to work again, I’d never have an education, never have relationships, never have anything in my life.” P9, M, Cannock“Write him off!” P10, F, Cannock“That’s what they done. They never told me there are people who do recover, so it’s not a life sentence.” P9, M, Cannock

GP Attitudes“Well, some people don’t come when they’re well and some don’t come when they’re sick and to be honest it’s a bit of a relief because I can catch up on being late.” GP4, F, Worcester

“They are notoriously bad at keeping appointments.” GP8, F, Birmingham

Lester HE, Tritter JQ, Sorohan H. Providing primary care for people with serious mental illness: a focus group study. British Medical Journal 2005;330:1122-1128.

The Role of Primary Care in FEP

Primary care is potentially crucial in the detection and referral pathway(Skeate et al, 2002; Burnett et al, 1999)

May lead to a reduction in DUP? Important in terms of ongoing family support

GPs and Referral Pathways

(at some point)McGovern (1991) 62% n=62

BirminghamCole (1995) 71% n=93 LondonLincoln (1998) 50% n=62 MelbourneBurnett (1999) 46% n=100 LondonSkeate (2002) 79% n=93 Birmingham

Working Practices in Primary Care

Random presentation of patients 10 minute time frame for assessment 269 million consultations each year, equivalent

to 740,000 people (1.3% of the population) each day

Multiple drivers and “must do’s’”

Methods Fit the Culture of Primary Care

Lack of research culture Competing priorities Question has to make sense to primary care Time/financial costs need to be minimal Minimal disruption to practice routine “Buy in” from PCTs

REDIRECT Methodology Cluster randomised controlled trial Not previously attempted in terms of FEP… Educational intervention of early detection training Primary outcome is number of referrals to EIS 160 patients (80 in each arm) Secondary outcomes of DUP, use of the MHA, time

to recovery Recruitment from 5/4/04-7/2/07 All practices have equal access to EI teams Sampling frame of 300,000 patients across 2 PCTs

in inner city Birmingham

Tailoring the Trial All data is collected in secondary care Training (intervention) is supported by the PCT Locum payments are made where additional training is

required Training emphasises the key role that primary care can

play Training imparts skills and knowledge i.e. has a CPD

value as well Regular but unobtrusive contact

Lester HE, Birchwood M, Tait L, Wilson S, Freemantle N. Design of the BiRmingham Early Detection In untREated psyChosis Trial:BMC Health services research 2005;5:19.

Developing the Educational Intervention

Theoretical phase: literature review and exploration of attitude and behaviour literature (e.g. contact hypothesis)

Modelling phase: focus groups and training needs analysis to explore what GPs wanted and needed to know and how the education should be structured and delivered

Content of the Educational Intervention

Video illustrating consultations in primary care facilitated by a GP

Written information e.g. challenging questions Year 2 and 3 follow up video training

facilitated by service users and carers using the contact hypothesis

Expected Changes Knowledge: increased awareness of symptoms

Skills: use of specific questions to elicit symptoms

Attitudes: more positive attitudes towards young people with psychosis and their families

Consultation changes? Withdrawal from family and friends Loss of concentration Depression/anxiety Loss of trust Self neglect

Hallucinations and delusions Thought disorder

+Family history

Drug misuse

Practice Recruitment and Training

148 practices approached in two waves of recruitment and 110 recruited (74.3%)

100% of practices had year 1 training, 69% year 2 and 50% year 3

65% of practices have had at least 2 training sessions

Training well received

Lester HE, Tait L, Khera A, Birchwood M. The development and evaluation of an educational intervention on first episode psychosis for primary care. Medical Education 2005;39:1006-14.

Results: Attendance and Feedback

0%

20%

40%

60%

80%

100%

KeyInformation

UsefulQuestions

ImprovedConfidence

GP Feedback (n = 53, 85%)

Patient Recruitment Primary outcome (referred for possible psychosis,

diagnosed as psychotic and then referred to EIS): 125

Those referred for possible psychosis, diagnosed as psychotic but NOT referred to EIS = 57

Total primary outcome of 182

Secondary outcomes: 83 with 6m follow up of 68

Results Neutral trial

9% increase in referrals from Intervention practices

No change in any secondary outcomes except for delay in reaching EIS (p 0.002)

Comparison Difference

Lower CI

Upper CI

P value

Delay_in_help_seeking -105.97 -267.49 55.5584 0.1949

Delay_in_help_seeking_pathway 4.0713 -51.5086

59.6513 0.8842

Delay_in_reaching_EIS* 222.03 83.5375 360.52 0.0021

Delay_within_MH_services 87.3422 -22.4520

197.14 0.1170

Duration_of_prodromal_period 59.3417 -290.21 408.89 0.7358

Duration_of_untreated_illness 187.23 -106.26 480.73 0.2072

Duration_of_untreated_psychosis

-13.7760 -199.12

171.57 0.8825

* time from first decision to seek care to referral to EIS

"Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases,

make a habit of two things — to help, or at least to do no harm."

Hippocrates: Epidemics, Bk. I, Sect. XI.

Did we do harm? False positive rate across the other mental

health services in the 6m pre trial was 9/67 = 13.4%

False positive rate in the subsequent 18 months was stable at 20/157= 12.7%

Who got stuck in services? 57 people in each of the 14 local MHTs Demographics were no different to the other EI

group 52/57 included a clear reference to psychosis

in the referral letter All were later confirmed as having a psychosis May have been a consequence of the waiting

list in the EIS in 2004

Implications GP education does no harm

GP education may simply do exactly what it says on the tin - enable GPs to diagnose youngpeople more quickly and refer them to EIS

GP education alone is not sufficient to increase referrals to EIS and decrease DUP

Primary care is just part of the jigsaw and interventions will need to be multifaceted

Thanks for listening