An epic journey

A psychiatrist at the Early Psychosis Prevention and
Intervention Centre in Melbourne, Australia, had to put up with a
bit of teasing recently after he wrote on a young person’s section
papers that the client could hear lions roaring – the centre is
next to the city’s zoo.

Aurelie Freeman is recounting this anecdote after her two-week
visit to the centre (Eppic) in March, courtesy of the 2003 Isabel
Schwarz travel fellowship. Freeman is the project manager for the
early intervention service at Central and North West London Mental
Health NHS Trust. Her role is to set up an early intervention and
psychosis service covering five boroughs – Brent, Kensington &
Chelsea, Westminster, Harrow and Hillingdon. In line with
government guidelines, this service will cover 14 to 45 year olds
to bridge the gap between child and adolescent mental health
services and adult mental health services.

Freeman was appointed last May. Since then she has set up a working
group that has drawn up a proposal for the service. This has been
endorsed by the trust and is being considered by the local
implementation teams in the five primary care trusts.

The proposal is for three teams: Harrow and Hillingdon; Brent; and
Kensington & Chelsea and Westminster. It is hoped that at least
one of these teams will be launched this year, but that depends on
funding.

So with this timetable in mind, Freeman flew to Australia to see
how one of the first such services in the world operates. Eppic was
set up in 1992 and now has about 90 staff in research alone and 100
in clinical work, as well as 44 research projects.

In February 2003, Eppic joined Orygen Youth Health and Research
Centre to provide services for 15-24 year olds. The advantage of
joint working is that young people can access services from both.
There is a central triage service for all new referrals where it is
decided whether to refer the client to the youth access team (Yat).
Yat staff work intensively and quickly with the client to assess
whether they should be referred to Eppic or Youthscope, Orygen’s
services for non-psychotic young people (see panel for more on
services).

Freeman spent a couple of days with Yat staff and sat in on two
assessments of new clients. “They’re a bit like our duty teams but
with a wider remit,” she says.

She was impressed by the speed of the service. “I sat in on one
assessment of a Vietnamese teenage boy whose uncle had phoned to
say that he was behaving strangely. Two days later, at a long and
careful assessment involving two staff and the uncle and father, it
was decided that he was psychotic. He was told then and there,
given some medication and leaflets. He was phoned that evening to
check that the medication was working. He was promised a home visit
in two days and told about a family meeting in the future.

“What was amazing was the speed with which all this was done. In
the UK it could take months to get to that stage. I was holding my
breath when he was told he had a psychotic illness, but he accepted
it and seemed ready to co-operate. I think that was to do with the
speed and thoroughness of the assessment.”

As well as assessing clients, Yat staff also see people in crisis
at any time of day or night, whether they have been accepted into
Eppic or Youthscope or are experiencing their first psychotic
episode.

Freeman was struck by the enthusiasm of the staff, who are
convinced of the importance of early intervention and are willing
to put themselves out. She spoke to one Yat nurse who was keen to
go out at night if a call came through about a young person
suspected of experiencing first-episode psychosis.

“It felt like a place with a common philosophy and that was
attractive and very encouraging. It was refreshing to see that
degree of enthusiasm,” she says.

Family work is also vibrant, she says. A social worker provides
specialist family work and supervision. Freeman visited one of the
three information sessions held in the evenings and open to family
and friends of people with psychosis. The first session looks at
what psychosis is, the second is about medication and the third
discusses issues of recovery. As well as disseminating information
the sessions allow parents to share their experiences and support
each other.

Eppic is currently recruiting family members to run a new
initiative called Families Helping Families, which will have a
phone line and drop-in centre. “The ethos is that the family is
part of the treatment programme,” says Freeman.

She noted several differences in work practices between the UK and
Australia. In Melbourne the youth service is huge, with a large
number of staff and greater investment in research. However, she
feels that the clinical side is probably more stretched there.
Although UK government guidelines stipulate that similar services
set up here must deal with 14 to 45 year olds, Eppic’s age group is
restricted to 15 to 24.

Eppic keeps clients on its books for only 18 months, whereas UK
government guidelines recommend three years, a timescale the
Australian staff thought better. The problem in the UK is that the
consequences of the wider age bracket are a higher number of
clients and a need for more staff, Freeman adds.

As Eppic has such a narrow age group, it is easier for the service
to be youth-focused, whether it is the posters that hang on the
walls of the centre to the music that is played – something that
would be much more difficult to tailor if the service is dealing
with teenagers and middle-aged clients.

The visit also confirmed some plans that she had for the service in
London. “I was having doubts about our proposal for an open
referral service so that individuals can be referred by anyone, but
staff at Eppic felt it was essential.”

She had believed that community education into psychosis would be
an integral part of setting up a service, and again this was borne
out by visiting Eppic.

“I’ve realised that it’s essential to have an excellent assessment
and triage service. You also need good case management systems to
ensure throughput of cases in the time constraints and fast
allocation methods. I saw how important the reception staff were.
They were warm, friendly and stable and that’s important in a place
where there could be a lot of anxiety.”

Freeman found the whole trip educational and is looking forward to
implementing some of the lessons she learned. She says: “After
spending time reading about it, it was incredibly exciting for me
seeing it in practice.”

EPPIC services   

• Two outpatient case manager teams.  
• An intensive case management team for assertive
  outreach.  
• A youth access team, which is a mobile assessment and crisis
  intervention team.  
• A clinic for young people who may be showing the first signs of
  psychosis.  
• A treatment resistance team. 
• Family work and group work.  

Eppic also has an in-patient unit with a ward attached. “It was
a wonderful modern purpose-built ward. I haven’t seen a psychiatric
ward like it,” says Aurelie Freeman. “It was light and clean, with
games, table tennis and music.”   Orygen provides a non-psychotic
side to the service with three clinics for eating disorders, mood
and anxiety disorders and emerging borderline personality
disorders. These clinics form Youthscope. There is another ward
that admits Youthscope clients.