The Singapore Early Psychosis Intervention Programme (EPIP): A programme evaluation
Highlights
► The Singapore Early Psychosis Intervention Programme (EPIP) was initiated in 2001 with the aim to reduce the duration of untreated psychosis and improve patient outcomes. ► EPIP is a part of National Mental Health Blueprint and hence has articulated a range of process and outcome indicators so as to that be accountable to stakeholders. ► At the end of 2 years of follow-up, 71.1% patients had achieved symptomatic remission and 76.5% patients had returned back to school or were gainfully employed.
Introduction
Psychosis generates an enormous burden in both economic cost and human suffering. The British National Health System (NHS) conducted a study (NHS Executive, 1996) on the financial impact of chronic diseases and found that psychosis was the most costly illness to treat. In a study conducted by the Ministry of Health Singapore (2004), schizophrenia was ranked among the top three leading causes of disability-adjusted life year (DALY) for Singaporeans aged between 15 and 44 years old.
Many studies have shown that those with psychosis usually experience considerable delay in receiving treatment. The average duration of untreated psychosis (DUP) reported in a number of Western countries is between 1 and 2 years (Johnstone et al., 1986, Larsen et al., 1998). A study of Singaporean patients with first episode psychosis found that the DUP ranged from 0.1 to 336 months, with a mean of 32.6 months and a median of 12 months (Chong et al., 2005a). There has been evidence to show that a shorter DUP is associated with faster and better response (McGorry et al., 1996). The alarmingly long DUP in Singapore and the probable severe consequences were the impetus for establishing a national Early Psychosis Intervention Programme (EPIP). Initiated in April 2001, EPIP is a comprehensive, integrated, and patient centered programme led by a multidisciplinary team of psychiatrists, psychologists, case managers, social workers, nurses and occupational therapists. The aims of the programme have been to:
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raise awareness of and reduce stigma associated with psychosis;
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establish links with primary health care providers and collaborate in the detection, referral, and management of those with psychosis; and
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improve the outcome of our patients and reduce the burden of care for their families.
Within two years of the launch of intensive community outreach and public awareness campaigns we were able to show a reduction of the median DUP from 12 months to 4 months and a positive shift in the referral pattern towards self, family, and primary care referrals as well as a reduction of 15% in police referrals (Chong et al., 2005b). In April 2007, EPIP came under the first-ever National Mental Health Blueprint developed by the Singapore Ministry of Health (MOH). The Blueprint has four main thrusts: mental health promotion, integrated mental health care, developing manpower, and research and evaluation. All programmes under the Blueprint are evaluated regularly on performance indicators established a priori so as to offer a multi-dimensional evaluation of the programmes and be accountable to the stakeholders.
The following indicators were set for EPIP based on the experience of the first five years of the programme, as well as the outcomes recommended within the international consensus statement on early psychosis (Bertolote and McGorry, 2005).
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Number of patients screened and accepted into EPIP
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DUP
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Number of primary workers trained in the community
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Proportion of patients with an improvement in their symptomatology at the end of 2 years
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Proportion of patients with an improvement in their level of functioning at the end of 2 years
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Suicide rate within first 2 years of diagnosis
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Proportion of patients who remained engaged with the service
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Levels of satisfaction with the EPIP service by patients
Details on the setting up of the clinical service and the different components of service provision of EPIP have been described in a previous paper (Chong et al., 2004), here we report on some of the outcomes that we set out to achieve.
Section snippets
Method
Patients accepted into EPIP from April 2007 to March 2011 were included in this analysis. Patients fulfilled the following criteria: (1) age between 15 and 41 years, (2) first episode psychotic disorder with no prior or minimal treatment, (3) no current history of substance abuse, and (4) no history of major medical or neurological illness.
Results
From April 2007 to March 2011, EPIP screened 1293 individuals and accepted 815 into the programme. Data from 795 patients were available for baseline analysis; 8 (1%) patients with ‘at risk mental state’ were excluded because of non-psychotic diagnosis and 12 (1.5%) patients had missing data. The sample comprised of 391 females (49.2%) and 404 males (50.8%) with a mean age of 27 years (±6.5 years) and ranged between 15 and 41 years. The mean DUP (SD) was 14.6 (±25.2) months and median was 6
Discussion
EPIP had articulated a range of process and outcome indicators which were used to evaluate the various aspects of our programme. A periodic report card on these outcomes makes the service accountable to stakeholders that include not only our funders, but also our patients and their families. Every 6 months report on our outcomes is submitted to our funding agency, i.e. the Ministry of Health, Singapore. In addition, information on some of our outcome measures are displayed on our website to
Conflict of interest
None.
Acknowledgements
None.
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