An evidence based approach

1
Early Psychosis

• An evidence based approach
• Julie Connor

2
Early Psychosis

• From little things big things grow
  ................................... .but some
  times we want to nip things in the bud!
• Work is the grand cure of all the maladies and
  miseries that ever beset mankind Thomas
  Carlyle, April 2 1866
• I must lose myself in action, lest I wither in
  despair Alfred, Lord Tennyson
  

3
Early Psychosis
4
What is Early Psychosis?

• Refers to an individuals first discrete
  experience of psychosis
• Psychotic illness
• can be brief or herald the onset of a more
  chronic illness such as schizophrenia. There are
  various proposed theories to describe the
  development of a psychotic illness.
• It can disrupt normal developmental
  trajectories.
• Early psychosis can result in significant
  individual disability and extensive social and
  economic costs.
• The WHO ranked active psychosis as the third most
  disabling condition, higher than blindness or
  paraplegia (2001)

5
Early Psychosis Data

• In one Australian study, 36 of first episode
  patients initial help seeking contacts were with
  a General Practitioner, but not always to their
  own family GP.(1)
• Psychotic disorders are low prevalence disorders,
  and can go unrecognised
• Most studies show that the duration of untreated
  psychosis (DUP) is between one and two years.(2)
• Mean delay between first symptoms and first help
  contact was 112 days, with a median of 31
  days.(3)
• Shorter DUP is associated with primary care
  contact(4)

6
Early Psychosis Data

• Short term course of illness strongly predicts
  long term outcomes, at 25 years after diagnosis
  (5)
• Effective treatment in the acute phase can
  minimise collateral damage to social, educational
  and vocational functioning (6)
• 1 in 5 young men with adolescent onset
  schizophrenia commit suicide (7)
• The highest risk of suicide is during the early
  post psychotic period (8)
• Social and other role loss can precede, accompany
  or result from a psychotic episode(9)
• Addington emphasised the need to intervene early
  and well. Reduction of the duration of untreated
  psychosis (DUP), and early and successful
  engagement in treatment, are key strategies in
  early intervention(2007)

7
Early Psychosis History

• During the 1990s there was increasing optimism
  about better outcomes for individuals with
  schizophrenia
• This interest flowed from the development of
  atypical anti-psychotics.
• Focus on the recognition that special attention
  to the early phase of illness could improve
  outcomes via a substantial reduction in morbidity
• Not a new idea
• Sullivan in 1920s, Cameron 1938, Meares 1959
• More recently, Falloon 1992, McGlashan 1996,
  McGorry 1998
• Currently an International Early Psychosis
  Association, (IEPA) with dedicated multi-centre
  international research efforts, international
  journal and a biennial conference (2008
  Melbourne, 2010 Amsterdam)
• IEPA has over 2500 members representing more than
  60 countries.

8
Why intervene in Early Psychosis?

• A long period of untreated psychosis before first
  intervention is known to involve distress for the
  individual and their family. This can include
  demoralising and unsuccessful attempts to obtain
  help, as well as the trauma associated with the
  psychotic episode.
• 20-30 of young people with a first episode of
  psychosis have been identified as risk to
  themselves or others in the period before
  effective treatment.(10)
• Cost effectiveness An Australian study using
  matched controls demonstrated a reduction of
  almost 50 in the cost of EPI services, sustained
  at 8 year follow up.

9
Why intervene in Early Psychosis?

• Cost effectiveness An Australian study using
  matched controls demonstrated a reduction of
  almost 50 in the cost of EPI services.
• 1 year out patient service was more expensive for
  EPI (5,666 vs 2,688)
• Weighted average cost favoured EPI (16,964 per
  patient vs 24,074)
• In patient costs favoured EPI (11,298 (42 days)
  vs 21,386 (80 days))
• At 8 year follow up, savings were
  sustained(15,372 vs 37,529) (2,599 pa vs
  5,178 pa) (11)

10
Early Psychosis Intervention

• National and international guidelines advocate
  for early intervention in the treatment of
  psychoses.
• It is recommended that early intervention
  services are developed to provide the correct mix
  of specialist pharmacological, psychological,
  social, occupational and educational
  interventions at the earliest opportunity NICE
  guidelines, 2003
• Promotion, prevention and early intervention are
  critical to enabling the community to better
  recognise the risk factors and early signs of
  mental illness and to find appropriate treatment
  COAG mental health action plan, 2006

11
Early Psychosis Intervention

• Rationale for early intervention
• Primary prevention of schizophrenia currently not
  achievable, but there is good evidence to support
  early intervention and secondary prevention.
• Early intervention aims for
• early detection of new cases
• shortening delays to attaining effective
  treatment
• provision of optimal and sustained treatment in
  the early critical phase of an otherwise
  potentially chronic illness.

12
Early Psychosis Guidelines

• NEPP (National Early Psychosis Project) published
  Australia specific clinical guidelines in 1998.
  These were ratified by the international EP body
  in 2002.
• Revised Australian guidelines are due for release
  in 2009.
• Clinical guidelines for the treatment of early
  psychosis have been noted to reduce inappropriate
  variation in clinical practice.

13
Early Psychosis Programmes

• In Australia, access to such Early Intervention
  programmes varies between geographic locations.
  In the absence of such services, the young person
  experiencing a psychotic episode might be
  introduced to the mental health service via the
  police, or a detained admission to a psychiatric
  ward.
• South Australian report published June 2008,
  recommended establishing a statewide Early
  Intervention service. The proposed model included
  the development of clinical links with, and
  referral pathways for, General Practice.

14
Interventions

• There is international and Australian evidence to
  support interventions in the treatment of
  patients presenting with a first episode of
  psychosis.
• An understanding of the range of appropriate
  treatments can facilitate timely, targeted mental
  health interventions.
• Psychopharmacological
• Psychosocial
• Cognitive
• Social
• Educational and vocational
• Families and carers

15
Psychopharmacological interventions

• RANZCP guidelines endorse atypical antipsychotic
  medication as the first line treatment for
  schizophrenia. The majority of patients report
  increased compliance and a more tolerable side
  effect profile with atypical antipsychotics.
• Typical antipsychotics have demonstrated efficacy
  in reducing symptoms, but have associated short
  and long term side effects, and are reported as
  less well tolerated, even at lower doses. These
  side effects are influential in the development
  of non-compliance.
• Atypical antipsychotics have been reported to
  attenuate the cerebral changes associated with
  psychosis, reduce positive and negative symptoms,
  and have fewer associated motor side effects.

16
Psychopharmacological interventions

• Poor medication compliance has been associated
  with lower occupational status, alcohol misuse,
  and increased delusions and suspiciousness(12)
• Some evidence that use of atypical antipsychotic
  medication promotes improved cognition in
  patients with early psychosis (13)
• The initial experience of parents involved with
  provision of medication has been reported as
  influential in both short and long term
  compliance(14)
• CAFÉ study

17
Psychosocial Interventions

• Cognitive Behavioural Therapy (CBT) has proved
  useful in ameliorating cognitive biases and
  distortions that are functionally related to the
  persistence of symptoms in psychotic illness(15)
• There is evidence of continued improvement in
  symptoms after cessation of individualised CBT
  (16)
• Support for CBT based on the SOCRATES trial
  (Tarrier, 2004), but benefits not replicated in
  all subsequent trials(17)
• CBT is a specialised form of psychological
  therapy, and research generally relies on skilled
  practitioners. CBT is predicated on some level of
  psychological mindedness in patients.(18)

18
Cognitive Interventions

• Neuropsychological impairment in episodes of
  early psychosis are well documented. They include
  generalised cognitive deficits, and specific
  memory, learning and executive function deficits
  (19)
• Research supports the targeting of specific
  cognitive processes in cognitive remediation to
  effect greatest change in psychosocial,
  educational and vocational functions(20)
• Evidence for CBT in specific interventions in
  FEP, including attenuation of positive
  symptoms(21), relapse prevention(22),and family
  and social skills interventions (23).

19
Cognitive Interventions I

• Recent application of cognitive strategies for
  patients with psychoses, mainly schizophrenia.
  Cognitive strategies are used in conjunction with
  low dose atypical antipsychotics.
• Focus of these interventions has been on
• Cognitive remediation and information processing
  deficits target the specific cognitive deficits
  and the behavioural correlates, that are
  associated with schizophrenia (eg poor social
  skills)

20
Cognitive Interventions ii

• Treatment of positive symptoms psychological
  treatments to reduce the occurrence and distress
  associated with persistent positive symptoms,
  such as auditory hallucinations or delusions
  (24). These therapeutic interventions have most
  value for patients experiencing residual symptoms
  that persist beyond the acute phase of their
  initial presentation(25)
• Secondary morbidity associated with psychosis
  important in the diagnosis, treatment and
  prognosis in FEP. Co-morbidity can result in
  modification of response to treatment, or
  necessitate multiple treatments. Substance abuse
  is a common co-morbidity, can include cannabis,
  stimulants, benzodiazapines, hallucinogens and
  anti-Parkinsonian drugs.

21
Cognitive Interventions III

• General psychological vulnerability to psychosis
  stress-diathesis model. A pre-morbid
  vulnerability alerts us to the increased risk to
  the individual of a frank psychotic relapse. A
  range of vulnerabilities are targets for
  cognitive interventions, including compromised
  information processing, psychological problems
  such as low self esteem, and specific
  developmental trauma.
• Impact of the disorder on the individual
  including the adaptation of the self to the
  psychotic disorder.

22
Social Interventions

• There is evidence of deficits in social skills
  even in the earliest stages of a psychotic
  episode.(26)
• Basic social skills training involves targeted
  work on specific social behaviours, such as eye
  contact and assertiveness training. (27)
• Goals of social skills programmes include
  improved functioning in general ADLs, employment
  and educational settings, and in relationships
• Quality of life at 1 year follow up significantly
  improved for individuals receiving social skills
  training as part of an EPI programme (28)

23
Educational and Vocational I

• No other technique for the conduct of life
  attaches the individual so firmly to reality as
  laying emphasis on work for his work at least
  gives him a secure place in a portion of reality,
  in the human community. Sigmund Freud
• 70-84 of people with schizophrenia are not in
  any paid employment, similar to USA and UK data
  (SANE, 2002)
• Paid employment can enhance self esteem, and
  fuller society participation, and increase
  financial independence.(29)

24
Educational and Vocational

• Everyone has the right to work Article 23,
  Universal Declaration of Human Rights, United
  Nations, 1948
• Paid employment is identified as the most
  important goal by FEP patients (30)
• Educational and vocational programmes have been
  successfully integrated into EPI services (31)
• Clearly documented gains exist from specialist
  vocational programmes in an EPI service
• 16 Randomised Controlled Trials of evidence based
  employment services in schizophrenia. 15/16
  demonstrated significantly better outcomes than
  controls(32)

25
Family and Carers I

• Family and carer work is essential in
  interventions in early psychosis, and has been
  identified in clinical guidelines (IEPA 1998,
  TOLKIEN II 2006)
• In FEP, negative symptoms and behavioural
  problems engender higher caregiver distress(33)
• 60-70 of individuals with first episode
  psychosis live at home with family(34), and 1/3
  of relatives have reported a depressive
  illness(35)
• In a 2007 survey more than a third of carers felt
  that they were not involved in decision making
  and many carers reported that they felt
  marginalized and invisible to medical
  services(36)

26
Family and Carers II

• Most family members of young people with FEP are
  keen to be involved in psychoeducation and
  recovery based interventions(37)
• Families report that they value the medical
  practitioners who provide information and
  emotional support (38)
• Family peer support fosters resilience and
  reassurance (39)
• Programmes such as Families Helping Families
  (40) provide models of intervention, including
  key components such as a monthly support group,
  a family resource room, and telephone information
  and support.

27
In Vivo Engaging the Young Person

• A collaborative doctor-patient relationship
  provides the foundation for effective treatment
  and therapy.
• Work form an assumption that the young person is
  doing their best, and treat them as responsible
  and capable
• Use clear communication, and check with the young
  person that they are understanding
• Avoid an authoritarian position explain your
  concerns and motivation to treat symptoms
• Use simple analogies where necessary

28
Engaging the Young Person

• Potential threats to engagement
• Stigma of mental illness persists, and can be 2
  sided.
• Denial and avoidance blame of others, use of
  substances
• Ambivalence change can seem intimidating and
  make preserving the status quo attractive
• Hopelessness can affect initial engagement and
  undermine treatment
• Coercion Young people often brought in by
  others, and therefore reluctant to engage on
  their own behalf.

29
Early Psychosis Safety

• Some patients presenting with an early psychosis
  are at high risk of suicide. They require
  specific and increased attention to suicide risk
  during their recovery.(41)
• No one strategy has demonstrated efficacy in
  preventing suicide, but there is some evidence to
  suggest that the following are helpful
• psychological interventions such as CBT,
• psychosocial support and psychoeducation
• treatment with atypical antipsychotics
• Programmes such as LifeSPAN(42)use cognitive
  strategies to address cognitions such as
  hopelessness, that are indicators of increased
  risk.

30
Summary

• In recent years, there have been significant
  advances in the treatment of an early psychotic
  episode.
• There is a solid evidence base for specific
  treatments in early psychosis.
• A short DUP is associated with more favourable
  outcomes.
• General Practitioners are integral to early
  detection and treatment, thereby shortening the
  DUP.
• In addition to pharmacological treatment,
  psychological interventions, as well as support
  for the patient and their family confer benefits
  in the short and longer term outcomes.

31
Questions?

• Questions?