Title: Understanding patient trajectories and predicting risk of poor long term outcomes in patients discharged from Early Intervention in Psychosis services
Funder: Department of Health and Social Care

Abstract: THE CLINICAL PROBLEMSchizophrenia and related psychotic illnesses are major contributors to the global burden of disease [1]. The likelihood of a full recovery decreases and the prospect of poor long-term health and social outcomes increases as the number of relapses of acute psychosis increase [2]. There is therefore a critical period early on in the illness where early treatment may reduce the probability of poor outcomes [3].EARLY INTERVENTION IN PSYCHOSISEarly Intervention in Psychosis (EIP) services provide rapid treatment to patients at risk of, or currently experiencing their first episode of psychosis (FEP). Teams provide care coordination, medication and psychological treatment, patient and family education, and physical health and social care. They are now widespread throughout England, with over 150 teams providing care to 10000 people annually, and this is likely to increase with many EIP services removing the upper age limit (usually 35 years) for referrals to the service.EIP treatment may reduce time in hospital [4], improve symptoms and social functioning [5], and reduce costs to the NHS [6]. However, treatment is only provided for three years and the treatment benefits made during EIP care may not be sustained at follow up after EIP treatment has ended [7,8].WHO NEEDS FURTHER TREATMENT?Not all patients are at risk of relapse. AESOP-10, a long-term follow-up epidemiological study of patients with FEP found that up to half of their patients had sustained remission and few acute psychotic episodes following their first-episode [9]. Targeting sustained early intervention only at those who are most likely to benefit from it would be a better use of resources. However, there is a lack of research investigating patient pathways and risk of relapse following EIP treatment.THE PROPOSED STUDYIn this programme of research I aim to investigate patients' clinical trajectories following discharge from EIP and characterise those at risk of relapse. I will conduct a systematic review of patient outcomes following specialist early intervention treatment. Then I will utilize the Clinical Records Interactive Search (CRIS) tool, an application which gives researchers access to anonymized patient records, to investigate patient pathways of all patients who have been treated by EIP services in four mental health trusts. I will identify and describe the discharge destinations of patients, investigate the demographic and clinical characteristics associated with patient discharge destination, map the clinical trajectories of patients for 24 months after discharge using latent class analysis, and determine demographic, clinical, and social variables associated with relapse following discharge using cox proportional hazard modelling.This research has the potential to benefit patients and the NHS in both the short and long-term. It will provide information on patient trajectories for many thousands of patients from diverse urban and rural populations. It will help policy makers, commissioners, and mental health professionals improve service planning for patients. By identifying patients who have a high risk of relapse this research will also help with the creation of targeted interventions to improve the transition process and aftercare of patients following discharge from early intervention.

Lay abstract: An Early Intervention in Psychosis (EIP) team is a community-based mental health team that aims to treat people who are experiencing symptoms of psychosis for the first time. EIP teams try to intervene as soon as people develop signs or symptoms. They treat them with a combination of medication (if appropriate) and talking therapy, provide advice and education about the illness to both them and their families, and help them manage their physical health and social needs through a case manager. Previous research has shown that EIP teams, in comparison to treatment by adult community mental health teams, reduce the amount of time people stay in hospital, reduce their psychotic symptoms, help them return to education and work, and save the NHS money. Optimism about the quality of treatment that EIP care can provide has led to the creation of over 150 EIP teams which treat over 10 000 people a year.Most EIP teams only treat someone for a maximum of three years. Once a patient is discharged from the team, they are usually cared for by either their general practitioner or an adult mental health team. However, because EIP teams are a relatively new service in the NHS, there is very little known about what happens to people once they have been discharged. Two randomized controlled trials which compared EIP to normal adult community mental health care found that when following up patients who had been part of the trials, the initial improvement made by patients whilst being under the care of EIP teams was not sustained after 5 to 10 years. These results suggest that the effects of EIP may only last whilst patients are being cared for by the service.In this study I aim to investigate what happens to patients once they are discharged from their EIP team. First, I will conduct a systematic review to find the current evidence for patients' long-term outcomes following EIP treatment. Then I will conduct a large-scale study to answer four important questions. First, which services care for patients once they are discharged? Second, what characteristics make patients more likely to be cared for by one service over another? Third, what are patients' care pathways for two years after leaving EIP services? Fourth, what factors might make patients relapse?To gather the data for this study I will use the Clinical Records Interactive Search (CRIS) tool, a computer application which anonymizes patient mental health records so that they can be used for research. I will link the CRIS tool in four mental health trusts, allowing me to analyse the data of an estimated 8500 EIP patients.This research will provide vital data that can be used by the services that care for people with psychosis. The knowledge of patients' pathways following their discharge from EIP teams could help policy makers, commissioners, and mental health professionals improve service planning for patients with early psychosis. A further benefit will be that this research could improve care by identifying the types of patients who may have a high risk of relapse. It could therefore help with the creation of targeted interventions to improve the discharge and the aftercare of patients who need it most.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH