A description of the

Australian Early Psychosis

Intervention Model and a
proposal to establish a Pilot
Early Psychosis
Intervention Program in
Bolivia.
Dr. Guillermo Rivera, MD,
MHPS, PhD.

First Episode of Psychosis typically

commences in young people: as do many of
the more serious mental disorders

Victoria (Aus) Burden of Disease Study: Incident Years Lived with

Disability rates per 1000 population by mental disorder

Agenda
1. Early Intervention in psychosis:
A paradigm of care for young people
2. The EPPIC Model
3. The Current State of Psychosis Treatment in
Bolivia
4. Arguments for early intervention in Bolivia
5. Programme Overview
6. Sustainability

1. Early Intervention in Psychosis:

A paradigm of care for young people
Early intervention in Psychosis is a paradigm of
care for young people with a first episode psychosis
and their families based on research and comprises
three concepts:
1. Early detection of psychosis
2. Reduce the long duration of untreated psychosis
3. Importance of the first 3-5 years following onset
(critical period) for later biological, psychological
and social outcomes

Aims of an Early Intervention

service
Reduce delays (& DUP) by:
promoting early detection and
collaborative engagement in the community

Optimise assessment & diagnosis by:

Comprehensive Bio/psycho/social assessment

Maximise recovery by:

providing integrated bio/psycho/social community Rx
focus on functional as well as symptomatic factors
addressing co-morbidity and treatment resistance early

Prevent relapse by:

ensuring assertive follow-up and psychoed. during critical period

Functioning

Intervening to reduce the Duration

of Untreated Psychosis (DUP)

Prodrome

First episode
of psychosis
2nd episode
of psychosis

rly ion &

a
E ect
det is
nt
e
s
i
Cr essm
s
As m
Tea

16
Age

20

24

Optimizing Inpatient Care and

Treatment in Early Psychosis

Functioning

Prodrome

First episode
of psychosis

16

FEP
Inpatient
20
services
Age

2nd episode
of psychosis

24

Intervening to Maximize Recovery

& Prevent Relapse

Functioning

Prodrome

First episode
of psychosis

16
Age

20

up
w
l o am
l
fo Te
e
tiv nity
r
se mu
s
A om 2nd episode
C
of psychosis

24

Implications of delayed treatment

Greater decrease in functioning
Loss of educational opportunities
Impaired psychosocial and vocational development
Personal suffering/family burdens
Potential poorer response once treatment is provided
Greater costs
Jackson, H. J., & McGorry, P. D. (2009). The recognition and management of early
psychosis: a preventive approach. Cambridge University Press.

Development of Early Psychosis Programs

Melbourne, mid-80s
Buckinghamshire, mid-80s
North Birmingham UK early 90s
Germany, 1990s (research1970s)
USA & Canada, early 90s
Scandinavia, mid-90s
Switzerland mid - 90s
Amsterdam, late 90s
Australia late 90s
UK 1999/2000
Far East & South East Asia, 2001
Networks: IEPA & European FE Schizophrenia Network

Early Psychosis Declaration

We need committed people,
we need good-will people, we
need grass-roots people.
this is a task for us all, each
one with their possibilities
and capabilities, but all
together

A collaboration between NIMHE / Rethink, IRIS, the

World Health Organisation and the International
Early Psychosis Association

2. The EPPIC Model

The Early Psychosis Prevention
and Intervention Centre
(EPPIC) in Melbourne has
pioneered early intervention in
Australia for young people with
psychosis.

Courtesy Orygen Youth Research Centre

EPPIC service
Western Region of Melbourne (pop = 850,000)
4 sectors

Inner West: (145,000)

North West: (266,700)
Mid west: (208,000)
South West: (237,600)

21

(Each sector has 20 CCU beds

for long-stay patients)

24
EPPI
C
16

21

24
South
west Area

= Acute adult
= EPPIC beds

Overview of
Mental Health Services For Kids & Youth
Western Region of Melbourne (800,000)
Youth Assessment Team

Prodrome

PACE
Clinic

Psychotic
Ages 15-30

Non-psychotic
Ages 15 -19

Older Adolescent Service

(follow-up to age 19)

Outpatient
Case
Management

Intensive
Outreach
Support

Acute
Inpatient
Care

EPPIC
(18 month follow-up)
Day
Group
Program

Family
work

Cognitive
Therapies

Specified aims of EPPIC

The early identification and treatment of the primary
symptoms of psychotic illness.
To improve access to, and reduce delays in, initial treatment
To reduce the frequency and severity of relapses, and to increase
the time to a first relapse
To reduce secondary morbidity in the post-psychotic phase of illness
To reduce the disruption to social and vocational functioning and
psychosocial development in the critical period following the onset of
illness, when most disability tends to accrue
To promote well-being among family members and reduce the
burden for carers

15

Clinical Staging of Psychosis

EPPIC provides a clinical service for up to 2 years to
young people aged 15- 24 years living in the
catchment area who have been diagnosed with a
first episode of psychosis.
EPPIC clinical work is provided in phases, according
to the phase of illness. In a first episode of psychosis
full recovery is possible with the appropriate
multidisciplinary multi-faceted treatment. As
treatment continues it needs to be tailored according
to both the needs of the individual and their
particular experience of the illness.

16

3. The Current State of Psychosis

Treatment in Bolivia
Less than half of the more than 250 adolescents and young adults*
who are estimated to experience a first episode of psychosis in the
city of Santa Cruz each year are ever diagnosed and receive
psychiatric treatment.
Patients who are eventually recognized as having a first episode of
psychosis are estimated to have experienced, on average, 2 years
of symptomatology prior to diagnosis. At this stage, psychiatric
treatment occurs most often in an inpatient setting and most
frequently follows an episode of aggression that places the patient
or others at risk for harm.
Most psychiatric treatment occurs in inpatient psychiatric hospitals
during lengthy stays, which in Santa Cruz are not publicly funded.
Outpatient options are limited.
* Incidence estimate is based on World Health Organization incidence rates for schizophrenia spectrum diagnoses in
15-24 year olds.
17

Barriers
There is an especially strong stigma of mental
illness throughout Bolivia.
Bolivia earmarked only 0.2% of its health budget
for mental health. There arent public psychiatric
facilities in Santa Cruz and all patients must pay
out of pocket for a significant portion of their
treatment
Bolivia has a especially low presence of
psychiatrists, with an average of only 1 per
100,000 inhabitants
Informe de la Evaluacin de Salud Mental en Bolivia Usando el Instrumento de la Evaluacin de los Sistemas de
Salud Mental de la OMS 2008.

Barriers 2
There is a lack of mental health training for
primary care health personnel. Limited ability to
appropriately screen for, identify, and treat
mental illnesses in the general population.
Bolivia has a highly fragmented medical system.
There are no electronic medical records. There
is limited coordination of care between individual
providers as well as between group providers,
such as clinics and hospitals.

Informe de la Evaluacin de Salud Mental en Bolivia Usando el Instrumento de la Evaluacin de los Sistemas de
Salud Mental de la OMS 2008.

4. Arguments for early intervention in

Bolivia
It does not require significant investment in
medical or physical infrastructure, technology or
high-cost, hard-to-obtain medications.
It does not rely heavily on psychiatrists, of whom
the supply is limited in Bolivia, or on a large
workforce of highly trained personnel.
On a per patient basis, early intervention is far
less costly than inpatient crisis treatment, which
is the current de facto standard of psychiatric
care for psychosis in this country.
20

4. Arguments for early intervention in

Bolivia
Our proposed early psychosis intervention
program represents a low-tech, appropriate and
potentially very transferable technology.
Bolivia does simply not need more mental health
care it needs a shift towards smarter, more
strategically organized, more economical care
and this programme would represent an
important step in this direction.
21

5. Programme Overview
A pilot early psychosis intervention program called
El Programa de Apoyo Temprano a la Psicosis
(PATAP) will provide age appropriate bio-psycho
social treatment and support for 15-25 years old
with first episode psychosis and their families,
who reside in the neighborhood of Plan 3000 in the
city of Santa Cruz de la Sierra, representing a
catchment area of 350,000.
22

23

PATAPS Aims
This programs specific objectives are to:
Improve short and long-term outcomes for those
with psychosis
Increase speed of recovery
Decrease the need for hospitalization
Reduce family disruption
Decrease rates of relapse

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Four Principal Components

28

Attention and Treatment

Service Model
Our programme will be implemented under a
"radial" model basis, where primary care,
responsibility and focus care program is in the
hands of current and leading providers of mental
health services (the "spokes"), but the contribution
of specialists is provided by a treatment team of
experts dedicated to first episode (the "hub").

27

The Hub

The team
manager
Administrator
Consultant
Psychiatrist
Consultant

Full-time position

The centralized Hub

provides support for the

Full-time position
Part-time position

spoke workers through

the delivery of clinical
supervision, training,
administration and

Part-time position

management.

Psychologist

The Spokes

Social Worker
Mental Health
Nurse
Assistant
Psychologist
Assistant
Psychologist

Full-time position
Part-time position

The community location

of the Spokes, provides
excellent opportunity to

Part-time position

encourage referrals from

local primary, voluntary
and generic youth

Part-time position

services, thus reducing

the DUP.

31

6. Sustainability
We do believe that public funding for mental illness
will increase over time, but it will take a significant,
concerted, well organized, and consistent lobbying
effort in order to make this change happen.
We have already begun working with and providing
support to the organization of family members of
people with psychosis in the city of Santa Cruz. We
will continue to work with this organization, training
and providing support in order to optimize their
lobbying efforts.
29

 What is currently most lacking in order to support any

lobbying effort for improved mental health treatment in
Santa Cruz is a programme such as we are proposing
that would provide a model of what mental health
treatment should actually look like.
Anyone with psychosis, should have a right to expect the
kind of comprehensive bio-psycho-social treatment that
our program proposes. This is the argument that we
believe we will be able to effectively make and
communicate towards the public and lawmakers over
time.
30

 Using terms often applied to sustainable

development, early psychosis intervention
programs represent an appropriate and
potentially very transferable technology.
Therefore, one of the principal goals of our
programme will be to create a model or blueprint
that might be replicated in similar communities
across Bolivia beyond Santa Cruz and possibly
in other developing countries.
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Summary
This program includes an innovative outreach program
that combines sound business principals with social goals
in order to specifically target the largest barrier to early
psychosis treatment in Bolivia: the stigma of mental
illness.
By utilizing a mobile, multidisciplinary treatment team that
emphasizes the roles of trained case managers focused
on providing intensive individual and family support in the
home, this program will provide culturally appropriate
care that will leverage contributions from a limited supply
of psychiatrists and shift dependence away from a
fragmented medical system.
32