Transcript Young people at high risk of psychosis

Introduction to At-Risk Mental
States
Why are we doing this work?
Introduction

What is the rationale behind detecting psychosis
early – is there a need?

What do ‘at-risk’ clients look like

Thinking about Services

A very brief history…
Psychosis: The Early Course
Adapted from
Larsen et al., 2001
Psychosis
premorbid phase
very early symptoms psychotic symptoms
Treatment & Recovery
The typical course of psychosis
Relapse?
Psychosis: The Early Course
Adapted from
Larsen et al., 2001
Psychosis
“DUP”
premorbid phase
very early symptoms psychotic symptoms
Treatment & Recovery
The typical course of psychosis
Relapse?
Psychosis: The Early Course
Adapted from
Larsen et al., 2001
Psychosis
Early Intervention after
onset of psychosis (EIS)
“DUP”
premorbid phase
very early symptoms psychotic symptoms
Tertiary Prevention
Treatment & Recovery
The typical course of psychosis
Relapse?
Psychosis: The Early Course
Adapted from
Larsen et al., 2001
Early Detection &
Intervention in the atrisk phase (ED:IT)
Psychosis
Early Intervention after
onset of psychosis (EIS)
“DUP”
premorbid phase
very early symptoms psychotic symptoms
Tertiary Prevention
Treatment & Recovery
The typical course of psychosis
Relapse?
Is there a need..?
‘Every year across the UK about 7,500 people will develop a
first episode of psychosis, onset usually occurring in
young people…
…this can lead to long term problems,
sometimes life long, which leave people on the margins of
society, struggling to maintain relationships, or get a job,
an income or a home.
As many as one in ten die by suicide, often within the first
five years, and their families, friends and communities
often carry huge burdens of care.’
(report on early detection & intervention - Parker et al 2007)
Is There a Need?
 Duration of Untreated Psychosis (DUP) remains approx. one year
after onset of psychosis
 Poorer outcome related to length of untreated psychosis (Drake et al.
2000; Yung et al. 2003)
 Significant disability associated with prodrome (Yung et al., 1996)
 Between 5 -15% of individuals with Schizophrenia will commit
suicide – most within the first six years of psychosis (Melle et al. 2006)
 Often the individual and family are in distress
Other Positives to earlier detection

Intervening early may improve engagement with services
(when insight is intact)

Reduce the trauma of hospitalisation & use of M.H. act

Intervening early may reduce psycho-social deterioration
Other Positives to earlier detection

Intervening early may improve engagement with services
(when insight is intact)

Reduce the trauma of hospitalisation & use of M.H. act

Intervening early may reduce psycho-social deterioration

The possibility to PREVENT psychosis in
vulnerable young people??
What do at-risk clients look like?
Employ PACE ‘at-risk’ criteria to identify:
 Familial risk plus reduced level of functioning in past yr
 or Attenuated psychotic symptoms
 or Brief, Limited, Intermittent Psychotic Symptoms
 Aged 16-35 years
Plus: Evidence of distress & difficulty
European Prediction of
Psychosis Study
Cologne
Berlin
Amsterdam
Turku
Birmingham
Manchester
EPOS : an international prospective study of transition to
psychosis in individuals at ‘ultra high risk’
EPOS Demographic Data 1
Sample size
Age (mean ± SD)
Gender (m : f in %)
Years of schooling (incl. university)
(mean ± SD)
Current work situation (n [%])
Full/part time work
In full time education
Unemployed
Unable to work (sickness/disability)
Other
246
23.0 ± 5.2
56.1 : 43.9
13.5 ± 2.8
55 [22.3]
99 [40.2]
36 [14.6]
43 [17.5]
10 [4.0]
EPOS Demographic Data 2
Current Partnership Status
Single
Married
Cohabiting
Separated/Divorced
Current Living Situation
Lives alone
With another person
In a family
Flat share
In an institution
n
200
10
34
2
n
61
29
123
30
3
%
[81.3]
[4.1]
[13.8]
[0.4]
%
[24.8]
[11.8]
[50.0]
[12.2]
[1.2]
EPOS Demographic Data 3 – it‘s not only
about psychosis
1° relative with psychotic disorder (n[%])
30 [12.2]
2° relative with psychotic disorder (n[%])
17 [6.9]
Schizotypal personality disorder (SIPS) (n[%])
33 [13.4]
Pre- or perinatal complications (n[%])
39 [15.9]
Any depressive disorder (n[%])
120 [48.8]
Any bipolar disorder (n[%])
19 [7.7]
Any anxiety disorder (n[%])
118 [48.0]
Any substance abuse disorder (n[%])
100 [40.8]
GAF score (mean ± SD)
51.0±11.8
BDI (depression - mean ± SD)
20.3±10.9
Participants with Suicidal Ideation at Baseline (BDI) - 55% n=232
I would like to kill myself if I
had the chance
I would like to kill myself
I've thoughts of killing
myself, but I won't carry
them out
I don't have any thoughts of
killing myself
0.0%
10.0%
20.0%
30.0%
Percent
40.0%
50.0%
Cannabis use of high risk patients
EPOS Study sites (n: 246)
Study sites EPOS
lifetime
recent-regular
use
> 5 times
during life
Last year ≥ once
a month
Cologne, Berlin
51.6 %
31.0 %
Birmingham, Manchester
47.2 %
34.0 %
Amsterdam
43.2 %
40.9 %
Finland
20.0 %
9.3 %
Total
42.0 %
28.6 %
Transition rate high risk patients
EPOS study centres (n=246)
Study sites EPOS
proportion
%
19/47
12/91
6/53
40.4 %
13.2 %
11.3 %
Turku
6/55
10.9 %
Total
43/246
17.5 %
Amsterdam
Cologne, Berlin
Birmingham, Manchester
EPOS Transition Rates
(To September 2006)
Total number of transitions
41
Transition rate (ref. to baseline)
12 months (n = 246)
31 (12.60%)
18 months (n = 246)
39 (15.04%)
Transition rate (ref. to risk set)
12 months (n = 199)
31 (15.57%)
18 months (n = 170)
39 (22.94%)
N at
baseline
Observation
Period (months)
Transition rate
246
12
18
12.6
15.04
Broome et al. 2005
58
?
10.3
Mason et al. 2004
74
>12, 26.3 ± 9.2
50%
McGlashan et al.
2006
60
29 (Plc)
17
12
12
24
26.7
37.9
29.4%
Miller et al. 2002
13
6
12
46.2%
53.8%
60
23 (TAU)
12
11.7
21.7
79
37 (ST)
12 (24)
16.5
27.0
75
18
24
24%
31%
Yung et al. 2004
104
(49+55)
6
12
27.9%
34.6%
Yung et al. 2006
119
6
10.1%
Study
EPOS
Morrison et al.
2004
Nordentoft et al.
2006 (SD ICD-10)
Pantelis et al. 2003
Treatment methods measured in EPOS
included:
- Medication (sorted by type e.g. Antipsychotic; Anxiolytic;
Antidepressant..
- Psychological Therapy (sorted by type e.g. CBT;
Psychotherapy..
- Monitoring (telephone / face to face etc)
- Group Therapies (e.g. for Social Anxiety)
- Family Interventions (e.g. Psychoeducation)
Medication and Psychological Therapy
D
Fin NL
Any psychotherapy (%) 41
Any meds
(%) 36
36
32
57
Neither
62
75
(%) 41 16
UK
Mean
95
50
-
59
43
28
Medication and Psychological Therapy
D
Fin NL
Any psychotherapy (%) 41
Any meds
(%) 36
36
32
57
Neither
SIPS+
62
75
(%) 41 16
8.7
9.1 11.6
UK
Mean
95
50
-
59
43
28
10.2
9.7
Medication and Psychological Therapy
D
Fin NL
Any psychotherapy (%) 41
Any meds
(%) 36
36
32
57
Neither
SIPS+
UK
Mean
95
50
-
59
43
28
9.1 11.6
10.2
9.7
7.7 10.9 29.8
11.9
14
62
75
(%) 41 16
Transition rate (%)
8.7
Medication and Psychological Therapy
D
Fin NL
Any psychotherapy (%) 41
Any meds
(%) 36
36
32
57
Neither
SIPS+
62
75
(%) 41 16
8.7
9.1 11.6
UK
Mean
95
50
-
59
43
28
10.2
9.7
7.7 10.9 29.8 11.9
Expected Transition without Intervention:
35 – 54%
Transition rate (%)
(SIPS/CAARMS)
14
Treating ‘at-risk’ clients




Confusion as to how to treat this cohort – not
‘psychotic’ but very unwell…
Little evidence as to the relative effectiveness of
medication / psychological therapies / case
management
Guidelines for treatments for HR group developed
by International Early Psychosis Association
(2005) but not consistently adopted by local
services
Early Detection Report (Parker et al 2007) – suggested
guidelines
Developing a Service Approach
Early Detection
Education,
Awarenessraising, Training
Engagement,
Appropriate
client/family
Treatments
Accurateassessment,
Evaluation
Developing a Service Approach
Early Detection
Education,
Awarenessraising, Training
Stigma & the media
Stigma – Public Attitudes to Mental Illness
 83% agreed society needs to adopt a more tolerant
attitude
 89% agreeing that society has a responsibility to
provide people with the best possible care
 74% agreed that mental illness is an illness like any
other
 20% said there is something about people with
mental illness that makes it easy to tell them from
normal people
Department of Health Survey (2003) : http://www.doh.gov.uk/public/england.htm (1897 adults, 16+)
Stigma – Public Attitudes to Mental Illness 2
 25% agreed that people with mental illness should be
excluded from public office and 16% said they should
never be given any responsibility
 Only 21% of respondents agreed that women who were
once in hospital for mental illness can be trusted as a
babysitter (31% neither agree/disagree)
 62% agreed that they would not want to live next door to
someone who has been mentally ill
 60% agreed that a woman would be foolish to marry a
man who has suffered from mental illness, even if he
seems fully recovered
Department of Health Survey (2003) : http://www.doh.gov.uk/public/england.htm (1897 adults, 16+)
Stigma & Psychosis
 70% of respondents rated people with schizophrenia
as dangerous to others
 80% rated people with schizophrenia as
unpredictable
 60% rated people with schizophrenia as difficult to
talk to
 50% thought people with schizophrenia would never
recover
Crisp, A.H., et al. (2002). British Journal of Psychiatry, 177, 4-7. (1737 adults 16+)
TIPS – Norway
DUP can be
dramatically
reduced through
educational
campaigns
ED:IT Mental Health Promotion
 ‘Mental health & Psychosis’ workshops for
individuals working with young people (300 +
attended)
 ‘Lunchtime workshops’ for MH professional
staff - training in ‘Early Identification’ of
psychosis (200 + attended)
 Educational DVD’s created by service users
of the Early Intervention Services
 ‘REDIRECT’ educational project for GP’s in
‘Early Signs’ of psychosis – reducing DUP
Developing a Service Approach
Early Detection
Engagement,
Appropriate
client/family
Treatments
Which Therapy for at-risk clients?


Evidence base for effectiveness of different
treatments for HR clients remains sparse
Psychological therapy suggested as more
acceptable, less stigmatising to HR clients (Bentall &
Morrison 2002)

Possible risk of pharmacological side-effects and
high non-adherence if antipsychotics used (eg
McGlashan et al. 2006)

Co-morbid symptoms (anxiety/depression etc)
addressed by psychological interventions
Interventions – Birmingham ED:IT
flexible treatment options including …
Intervention Type
Case
Uptake
n=50
100.0%
Management
Individual
CBT (Morrison & French, 2004)
86.7%
Group
CBT
24.4%
Family
Support/Intervention
35.5%
Neuroleptic
Meds (supplied by outside
agency)
ED:IT Sept 2004
6.7%
EDIE2 (MRC funded UK Intervention Trial 2006
- 2010)
MRC funded Trial of CBT for individuals at
high risk of psychosis
 Aim to recruit n=320 high-risk participants
 To reduce transition to psychosis and
reduce the distress felt by help-seeking
individuals
 Inclusion using PACE at-risk criteria

What sites are involved in EDIE 2?
Manchester (lead site)
 Glasgow
 Birmingham/ Worcester
 East Anglia
 Cambridge

Check EDIE2 website at University of Manchester
That’s the theory… but does it
work in practice?

Are we able to ‘detect’ young people in the
pre-psychotic phase in the community?

Do these young people actually want help
from (mental health) services?

Is the ‘help’ that we are offering acceptable
to young people?
That’s the theory… but how is it
working in practice?

Are we able to ‘detect’ young people in the
pre-psychotic phase in the community?

Do these young people actually want help
from (mental health) services?

Is the ‘help’ that we are offering acceptable
to young people?
YES
A very Brief History of treatments for
Psychosis (to remind us where we’ve
been…)
Dunking Pool
1403 - St Mary of
Bethleham hospital near
London first accepts
psychiatric patients
(from 1776 this was also a
tourist attraction)
Head Restraint
Restraining Crib
(single occupancy)
Lobotomy Kit (NHS
outreach model)
1890 - Dr Gottlieb
Burkhardt attempts
to alter behaviour in
6 severely agitated
Swiss patients by
extracting portions
of their frontal lobes
(2 died)
Portable ECT
Machine
1913 - Emil Kraepelin
categorises mental
illnesses into those which
could be cured and those
which could not
(e.g.dementia praecox psychosis)
1938 - Cerletti and Bini
introduce electroshock
convulsions
1952 - Deniker Leborit
& Delay discover the
antipsychotic
properties of
chlorpromazine
marking the
beginning of
psychopharmacology
1955 - More than
55,000 men women
and children in the
US undergo
lobotomy
1985 - Ian Falloon trains GP’s to identify ‘early signs’ of
psychosis
1990’s - EPPIC / PACE establish Early Detection/Intervention
Clinical & Research programmes in Melbourne
- Early Intervention approaches introduced in UK and
Internationally
- TIPS Norweigian educational campaigns reduce DUP
2000’s – First Early Detection / Prevention Programmes in UK
EDIE(2), ED:IT, OASIS, REDIRECT, BRITE
1985 - Ian Falloon trains GP’s to identify ‘early signs’ of
psychosis
1990’s - EPPIC / PACE establish Early Detection/Intervention
Clinical & Research programmes in Melbourne
- Early Intervention approaches introduced in UK and
Internationally
- TIPS Norweigian educational campaigns reduce DUP
2000’s – First Early Detection / Prevention Programmes in UK
EDIE(2), ED:IT, OASIS, REDIRECT, BRITE
That’s a big jump in 20 years…
1985 - Ian Falloon trains GP’s to identify ‘early signs’ of
psychosis
1990’s - EPPIC / PACE establish Early Detection/Intervention
Clinical & Research programmes in Melbourne
- Early Intervention approaches introduced in UK and
Internationally
- TIPS Norweigian educational campaigns reduce DUP
2000’s – First Early Detection / Prevention Programmes in UK
EDIE(2), ED:IT, OASIS, REDIRECT, BRITE
so what’s next…?
ED:IT Birmingham
Telephone:
Fax:
0121-301 1850
0121-301 1851
email: [email protected]