Impact case study database

Psychosis can have a devastating effect on quality of life, including reduced engagement with work, education, and social activity. Recent estimates suggest only 5-15% of people with schizophrenia are employed, compared with over 70% of the general population. This lost productivity costs the English economy GBP3,400,000,000 per year (Andrew et al., 2012). UEA research demonstrates the importance of implementing psychological interventions to ameliorate the personal and societal challenges posed by psychosis.

Psychological treatments for Psychosis

UEA research has informed the evidence base underpinning clinical guidelines for the prevention and treatment of psychosis in the UK (since 2014) and the US (since 2019). These guidelines, in general use in the UK and US, recommend that everyone diagnosed with psychosis be offered psychological therapies.

The influential cognitive model of psychosis (Output 1) is cited in UK NICE guideline for the ‘Treatment and Management of Psychosis and Schizophrenia in Adults’ ( Source 1, p. 26). The guideline refers to the cognitive model of psychosis when emphasising the importance of considering psychological factors in the development, and therefore treatment, of psychosis. NICE guidelines recommend that CBTp and family intervention should be offered to all adults with psychosis. Research conducted at UEA is cited in the evidence review underpinning this guideline. Output 2 is included in the evidence review for CBT for psychosis and in the evidence review for family intervention ( Source 1, p. 225). UEA research is also cited in UK clinical guidelines for treating psychosis in children and young people, in support of the recommendation that individual CBT should be offered to young people with transient or attenuated psychotic symptoms (Output 3, Source 2, p. 249).

Offering CBTp and family intervention to all adults with psychosis are Quality Statements in the NICE ‘Psychosis and Schizophrenia in Adults Quality Standard’ (2015) document. The document outlines the potential positive impact of psychological interventions in improving outcomes for service users. Quality standards set out priority areas for quality improvement in health and social care. Critically, these standards are having a widespread impact on practice. Data from the National Clinical Audit for Psychosis highlight that 49% of people ( N >5000) with a first episode of psychosis received CBTp in 2019/20 ( Source 3).

The recently published American Psychiatric Association guidelines ( Source 4) cites the NICE guidelines ( Sources 1 & 2) and directly cites UEA research in the evidence review for the recommendation that individuals with schizophrenia who have ongoing contact with family should receive family interventions (Output 2, Source 4, p. 262). Output 2 is also cited on the American Psychiatric Association training slides ( Source 5) ; these slides are used in the training of psychiatric professionals in the US and in Continuing Professional Development for psychiatric and clinical professionals.

Early Intervention for Psychosis Services

UK guidelines have been developed to specifically emphasise the importance of timely implementation of NICE recommended treatments, including access to specialised multi-disciplinary Early Intervention in Psychosis (EIP) services. In 2016, NHS England released the Access and Waiting Time Standard for Early Intervention in Psychosis Services ( Source 6). Implementation of the standard is required in all EIP services in England. This was the first Access and Waiting Time Standard for mental health and requires that people with first episode psychosis are able to access specialist EIP services within two weeks of referral and be offered NICE recommended packages of care, including CBTp. These important developments in guidelines for clinical practice and patient care were greatly influenced by research carried out at UEA. Output 4 is cited in the Access and Waiting Time Standard ( Source 6, p. 20) as evidence of the clinical and cost-effectiveness of a ‘standalone’ model of EIP service provision. Data from the National Clinical Audit for Psychosis highlight that 10,560 people with a first episode of psychosis accessed EIP services across 155 teams in England in 2019/20 ( Source 3). As a result of using EIP services, people are less likely to be admitted into hospital and more likely to live independently and return to employment, with an estimated potential annual cost saving of GBP63,300,000 to the NHS and wider society.

Social Recovery Therapy (SRT): Impact on training and outcome measurement

Findings from the SUPEREDEN3 trial (Output 5) have generated significant interest in SRT as an intervention to improve functional outcomes for people with psychosis. An overview of the findings have been published as an NIHR Signal (2018) by the NIHR Dissemination Centre ( Source 7). NIHR Signals aim to fast-track the implementation of new research evidence by providing healthcare decision-makers with outcomes of important health research. The Signal states: *“ **Social Recovery Therapy not only increases structured activity levels but also appears to keep people in contact with services in the first critical nine months. It could be incorporated into early intervention services for people with persistent social withdrawal.*” The trial also featured in a NIHR Dissemination Centre Themed Review on support for people with severe mental illness (Output 5 cited in Source 8, pp. 28, 40-41, 46). Data from the NIHR Dissemination Centre shows that the Themed Review was accessed/downloaded 6,102 times between March 2018 and November 2020.

There has been significant interest in SRT from clinicians working with people with psychosis nationally and internationally. SRT is being used in Ireland at NUI Galway. Until recently there was no specific service provision for young people with first episode psychosis in Ireland. However, in 2019, a new Model of Care for Early Intervention for Psychosis services was launched by the Irish Health Services Executive and three pilot EIP services were set up in 2020: “ When searching the literature in early 2019 we found that Social Recovery Therapy (SRT) - developed by Prof David Fowler, Dr Jo Hodgekins and colleagues – showed the most positive effect on functional recovery outcomes compared to other interventions. [SRT] has greatly informed our thinking around interventions to improve functional outcomes for people with psychosis and we have chosen to include this approach in our programme of research and service development.”* ( Source 9).

Training in the use of SRT has been delivered to clinicians undertaking the PGCert in Enhanced CBT for Psychosis and Bipolar Disorder at the Oxford Cognitive Therapy Centre. The training received excellent feedback with clinicians. In conjunction with the Time Use Survey tool to assess social recovery outcomes (Output 6), SRT resources have been developed for clinicians (including a therapy manual and training videos) and are available via a Social Recovery Therapy website which was launched in January 2020 ( Source 10). Illustrative analytics data from December 2020 showed that monthly visits to the website had increased by 300% since Summer 2020, with over 100 visits per month from across the world, including UK, USA, Hong Kong, China and Ireland. In addition, the website is cited in the resources area of the American Institute for Cognitive Therapy.

Summary

Enhancing clinical practice to improve the lives of service users and their families has been at the heart of the UEA research programme. The research outlined here has emphasised the importance of psychological factors in the development of psychosis and has increased the availability and variety of treatment options for service users and their families. Moreover, broadening the focus of psychological approaches to include social and functional aspects of recovery has influenced a holistic range of outcomes. UEA research has changed clinical practice by informing both national and international guidelines and contributing to a focus on Early Intervention for Psychosis services. This has improved the lives of individuals and reduced the societal burden of this devastating illness.