Transcript Ethical issues in research in people at high risk of psychosis

IEPA clinical
practice guidelines
for ARMS
Shôn Lewis
University of Manchester
UK
Early phase terminology
• High risk
– Psychosis proneness; schizotypy
• Isolated psychotic symptoms
– Psychosis like experiences
– Non-clinical/subclinical psychotic symptoms
• Early prodromal
– Bonn scale
• At risk mental state
– Late prodromal
• First episode psychosis
Early phase terminology
• High risk
– Psychosis proneness; schizotypy
• Isolated psychotic symptoms
– Psychosis like experiences
– Non-clinical/subclinical psychotic symptoms
• Early prodromal
– Bonn scale
• At risk mental state
– Late prodromal
• First episode psychosis
Early phase terminology
• High risk
– OLIFE; SPQ
• Isolated psychotic symptoms
– LSHS
– PDI; CAPE
• Early prodromal: SPIA
• At risk mental state
– CAARMS
– SIPS/SoPS
• First episode psychosis
– PANSS etc
Constructs
↑ risk of
Psychotic
psychosis symptom
High risk
Isolated pic
symptom
Early
prodromal
ARMS (late
prodromal)
1st episode
psychosis
Distress
Help
seeking
Need for
treatment
Constructs
↑ risk of
Psychotic
psychosis symptom
High risk
Isolated pic
symptom
Early
prodromal
ARMS (late
prodromal)
1st episode
psychosis
Distress
Help
seeking
Need for
treatment
Constructs
↑ risk of
Psychotic
psychosis symptom
High risk
Isolated pic
symptom
Early
prodromal
ARMS (late
prodromal)
1st episode
psychosis
Distress
Help
seeking
Need for
treatment
Constructs
↑ risk of
Psychotic
psychosis symptom
High risk
Isolated pic
symptom
Early
prodromal
ARMS (late
prodromal)
1st episode
psychosis
Distress
Help
seeking
Need for
treatment
Constructs
↑ risk of
Psychotic
psychosis symptom
High risk
Isolated pic
symptom
Early
prodromal
ARMS (late
prodromal)
1st episode
psychosis
Distress
Help
seeking
Need for
treatment
Constructs
↑ risk of
Psychotic
psychosis symptom
High risk
Isolated pic
symptom
Early
prodromal
ARMS (late
prodromal)
1st episode
psychosis
Distress
Help
seeking
Need for
treatment
At risk mental state: Yung et al 1998
• Attenuated positive symptoms
– subthreshold for severity
• Brief limited intermittent psychotic symptoms
– subthreshold for duration (<1 week)
• Schizotypal personality or first degree relative
with psychosis plus recent functional
deterioration
• Seeking help
High risk of acronyms
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•
•
•
•
•
•
•
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PACE
PRIME
EDIE
RAP
FETZ
TOPP
PIER
OASIS
EPOS
CARE
NAPLS
SPAM
– Society for Prevention of Acronyms in Mental health
Rates of one year transition ARMS to
psychosis (adapted from Lisa Phillips et al 2005)
Centre
PACE
PRIME
TOPP
EDIE
PIER
Transition rate
41%
38%
43%
26%
23%
IEPA clinical guidelines for early psychosis
•
•
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Formulated Copenhagen 2002
29 authors A-Y
Published 2005
To be updated 2008
Covered
– ARMS
– First episode
– Recovery (6-18 months) and critical period phase
IEPA writing group Br J Psychiatry 2005 187
s48 s120-124
Prevention in early psychosis
• Three targets for preventative
interventions in early psychosis
– Prepsychotic phase
– Initially untreated psychosis
– First episode
IEPA writing group Br J Psychiatry 2005 187
s48 s120-124
General statements
• Early identification will reduce burden
– May improve long term outcomes
• Public education important
• Careful, low dose drug treatment in first
episode
• Psychosocial treatments important in
promoting recovery
• Users and families engaged in developing
better treatments
IEPA writing group Br J Psychiatry 2005 187
s48 s120-124
The prepsychotic period: clinical guidelines
• At risk mental state needs to be
considered in young people with
deteriorating functioning or unexplained
agitation
IEPA writing group Br J Psychiatry 2005 187
s48 s120-124
The prepsychotic period: clinical guidelines
• Help seeking people with ARMS need to
be engaged and assessed and offered
– Regular monitoring and support
– Specific treatment for depression or
substance use
– Psychoeducation and help to develop coping
skills
– Family education and support
– Information about risks of psychosis
IEPA writing group Br J Psychiatry 2005 187
s48 s120-124
The prepsychotic period: clinical guidelines
• Care offered in a low stigma environment
– At home; primary care; youth-friendly office-based
setting
• Antipsychotic drugs not usually indicated
– Exceptions might be risk of suicide or violence, or
rapid deterioration
– If used, regard as therapeutic trial for up to 6 weeks
• If help declined, consider support from friends
and family
IEPA writing group Br J Psychiatry 2005 187
s48 s120-124
What are the outstanding issues
now?
Issues for ARMS interventions
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•
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Safety and acceptability
Efficacy and effectiveness
Availability and cost
What is the therapeutic target?
– Prevention versus treatment
• Ethics
– Of treatment; Of non-treatment
• Population impact
IEPA writing group Br J Psychiatry 2005 187
s48 s120-124
Issues for ARMS interventions
• Refinement of risk estimates
• Modifying risk and protective factors
• Developing a clinical algorithm
– Psychological intervention first?
– Drug treatment second?
– How long for?
IEPA writing group Br J Psychiatry 2005 187
s48 s120-124
Which psychological intervention?
• Cognitive therapy (Morrison et al, 2006;
Ruhrman et al, 2007)
• Also? (from psychosis literature)
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–
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Family intervention
CT for relapse
Motivational interventions
Cognitive remediation
Which drug treatments?
• Antipsychotics?
– Appear effective
• RCT data with risperidone; olanzapine; amisulpride
– BUT risks from side effects: low NNT:NNH ratio
– Doubtful acceptability for many
• Antidepressants?
– Anecdotal evidence
Roll on the IEPA guideline
update!
EDIE trial: Results
Transitions to psychosis at 12 months
30
25
20
control
CBT
15
10
5
0
PANSS
Medication
Diagnosis
Morrison et al, 2004