高等院校医药类课件-Rationale-for-Early-Interventions-is

PaulFrenchPsychologyServicesofSalfordBoltonSalford&TraffordMentalHealthTrust&DepartmentofPsychologyManchesterUniversityRationaleforEarlyInterventionsinPsychosisEarlyDetectionandInterventionTeamCollaboratorsTonyMorrisonRichardBentallShonLewisMaxBirchwoodAndrewGumleyAssistantsLaraWalfordAoiffeKilcommonsJoanneGreenAliceKnightMarianneKreutzSandraNeilUmaPatelSophieLomaxShreetaRajaWhatisEarlyInterventionEarlyinterventionstrategiesInterveningearlywithpeoplewhoarerelapsingfromanestablishedillnessInterveningwithpeopleintheearlystagesoftheirillness(criticalperiodhypothesis)includingearlycaseidentificationEarlyinterventionasapreventativestrategyWhyEarlyIntervention?EmilKraepelin

(1856-1926)

Discoveredschizophreniaandmanicdepression.Degenerativebraindisorder.CurrentresearchinterestStressvulnerabilityStressVulnerabilityPrognosis(roughlyspeaking)Anearlyinterventionservice

shouldbeabletoReducethestigmaassociatedwithpsychosisandimproveprofessionalandlayawarenessofthesymptomsofpsychosisandtheneedforearlyassessmentReducetheamountoftimeyoungpeopleremainundiagnosedanduntreatedDevelopmeaningfulengagement,provideevidencebasedinterventionsandpromoterecoveryduringtheearlyphaseoftheillnessAnearlyinterventionservice

shouldbeabletoIncreasestabilityinthelivesofserviceusersfacilitatedevelopmentandprovideopportunitiesforpersonalfulfilmentProvideausercentredservice,seamlessbetween14to35integratingchild,adolescentandadultservicesandworkinpartnershipwithprimarycare,education,socialservices,youthandotherservicesAttheendofthetreatmentperiodensurethatcareistransferredthoughtfullyandeffectivelyDurationofUntreatedPsychosisDUP theamountoftimefromonsetof symptomsofpsychosistothe prescriptionofantipsychoticmedicationDurationofUntreatedIllnessDUI theamountoftimefromtherecognition thatthingsarenotgoingwelltothe prescriptionofantipsychoticmedicationDurationofUntreatedPsychosisDurationofuntreatedPsychosisandDurationofuntreatedillness050100150200250300350400450500Loebeletal1992Beiseretal1993Hafneretal1993McGorryetal1996Drakeetal2000StudiesWeeksDUPDUIExerciseIfyouoramemberofyourclosefamilystartedtodeveloppsychosiswouldyoufeelcomfortablegettinghelp?Whatmightpreventyoufromgettinghelp?Whathelpwouldyouwant?Isthisavailable?ConsequencesofdelayedtreatmentSlowerandlesscompleterecoveryPoorerprognosisIncreasedstigmaIncreasedriskofdepressionandsuicideInterferencewithpsychologicalandsocialdevelopmentStrainonrelationships;lossoffamilyand

socialsupportsDisruptionofparentingskills(ifhavechildren)Consequencesofdelayedtreatment(cont’d)Disruptionofstudy,employmentandunemploymentSubstanceabuseViolence/criminalactivitiesUnnecessaryhospitalisationLossofselfesteemandconfidenceIncreasedcostofmanagementPotentialbenefitsofearlyinterventionImprovedrecovery1,2Morerapidandcompleteremission2,3BetterattitudestotreatmentLowerlevelsofexpressedemotion/familyburden4Lesstreatmentresistance1.BirchwoodandMacmillan,19932.McGorryetal,19953.Loebeletal,19924.Stirlingetal,1991@easeispartofRethink—Workingtogethertohelpeveryoneaffectedbyseverementalillness,includingschizophrenia,torecoverabetterqualityoflife.Weprovidepracticaladvice,supportandinformationtopeoplewhohaveaseverementalillness,theirfamiliesandfriends.Andweworkforabetterunderstanding,breakingdownthestigmaandmythsaboutmentalillness./at-ease/NorthwickParkStudy

Johnstoneetal1986Studyoffirstepisodeschizophrenian=25328%admittedwithin2months25%admittedbetween2-6months9%admitted6-12months26%admittedaftermorethan1yearNorthwickParkStudy

Johnstoneetal198641%ofpatientsmadecontactwitheitherahospital,aGP,privatemedicinefaculties,socialworkers,religiousbodies,marriageguidance,etc13%hadmademorethan9helpercontactswithoutreceivingtreatmentNorthwickParkStudy

Johnstoneetal1986Asubsamplen=120wasincludedinanRCTtotestantipsychoticmedicationagainstplacebo.TheyfoundthatDUPwasastrongerpredictorofrelapsethanantipsychoticmedication.TheTIPSProjectEarlydetectionsystemsforschizophreniaappeartobeeffectiveinimprovinghelp-seekingbehavior,thusreducingdurationofuntreatedpsychosis(DUP),claimresearchers.Theystressthatthiscouldhaveimportantpublichealthimplications,particularlyasashorterDUPhasbeencorrelatedwithabetterprognosis.TheTIPSprojectsuccessfullyreducedDUPfrom114weekstoameanof26weeks,adifferenceofaboutoneandahalfyears.CaseMaterialIrememberwhenIhadmyfirstepisode;Iwasabout21atthetime.Ididn’thaveacareintheworld,Ihadmyownhouseandalongtermrelationship,andthingscouldn’thavebeenmoreperfect.SowhenIfoundmyselfhidingunderthequiltworriedthatmyboyfriendwassomehowtryingtokillme,wellyoucanimagine,it’saveryscarythought.WhocouldItellwithoutthemthinkingIwasmad?Iwasevenworriedaboutdiscussingitwiththepeopleclosetomeatthetime;afterallIthoughtmyboyfriendwastryingtokillme.Maybeeverybodyelsewas,perhapstheywereallplottingagainstmesomehow.Thiswasjustoneofmanyirrationalthoughtsthatcameintomyheadandthereweremanymore.LookingbackonitnowthethingsIthoughtthenseemsosillynowbutofcoursetheydidn’tatthetime.

Whatdopeoplewant?Ijustwantedanswersoratleastalisteningear;insteadIwashandedoveraprescriptionofantidepressantsandtoldtherewasbasicallynothingwrongwithme.Iftherewasnothingwrongwithmewhatwastheprescriptionfor?WhatHappensintheEarlyStages?Imadefurtherattemptstovisitthesurgeryandbythistimethingshadgotconsiderablyworseforme.MonthshadpassedandInowhadanewtheorymaybeIhadabraintumourandthiswasthereasonwhyIwasill.Ihadswappedonefearforanother,anditwasonlythenthedoctordecidedtorefermetosomeoneelse.AtlastIthoughtmyprayershadbeenanswered,however,yetagainitprovedaverydifficultroadahead.HowYouFeelIwaseventuallyreferredtosomebodywhothenreferredmeagaintosomeoneelseandatthispointIfeltlikethelostluggageyougetattheairport,nobodyknewquitewhattodowithme,thiswasquiteunnervingforme.Whatcanwedotoalterthis?WorkwithpeoplewhoareintheearlystagesofpsychosisHowearlyisearly?Birmingham.au/AimsandObjectives:Earlyidentificationandtreatmentofprimarysymptomsofpsychoticillnesswithcorrespondinglyimprovedaccessandreduceddelaysininitialtreatment.Reductionoffrequencyandseverityofrelapseandincreaseintimetofirstrelapse.Reductionofburdenforcarersandpromotionofwell-beingamongfamilymembers.Reductionofsecondarymorbidityinthepostpsychoticphaseofillness.Reduceddisruptioninsocialandvocationalfunctioning,andinpsychosocialdevelopmentinthecriticalperiodoftheearlyyearsfollowingonsetofillnesswhenmostdisabilitytendstoaccrue.ExerciseWhatdoyouthinkwouldbeimportantfactorsassociatedwithpredictingsomeoneisatriskofpsychosis?Howdowepredictpsychosis?FamilyhistoryGeneralpopulationratesare 1:100Oneparentwithschizophreniathen 10:100Bothparentswithschizophreniathen 45:100HoweverOnly11%ofcasesofschizophreniawillhaveaoneormoreparentswiththesamediagnosis,whilst37%ofallcasesofschizophreniawillhaveneitherafirstoraseconddegreerelativewiththesamediagnosis(Gottesman&Erlenmeyer-Kimling2001).Ageofonsetforschizophrenia05101520253035age12-14age15-19age20-24age25-29age3034age35-39age40-44age45-49age5054age55-59PercentageFemales%Males%AssessmentsforIdentificationBriefPsychiatricRatingScale(BPRS)Lukoff,Neuchterlein&Ventura(1993)PositiveAndNegativeSyndromesScale(PANSS)Kay,Fiszbein&Opler(1987)ComprehensiveAssessmentofAtRiskMentalStates(CAARMS)PaceclinicYungetal2002StructureInterviewforProdromalSymptoms(SIPS)ScaleofProdromalSymptoms(SOPS)PrimeclinicMcGlashen,Miller,Woods,Rosen,Hoffman&DavidsonBonnScalefortheAssessmentofBasicSymptoms(BSABS)Klosterkoette,Schultze-LutterPredictionofPsychosis

Klosterkotteretal.ArchGenPsychiatry.2001;58:158-164

N=110RecruitedfromaspecialistclinicAssessedusingtheBSABSFollowupover9.6yearsInthissampleofnonpsychoticoutpatients,ofthosewhoreportedatleastoneprodromalsymptomontheBSABS,70%subsequentlydevelopedthepsychosisPredictionofpsychosis

Yungetal.1998UsedtheBPRSAgebetween14and30years ANDFamilyhistoryofDSM-IVpsychoticdisorderandreductiononGAFscaleof30, AND/ORAttenuatedsymptoms,occurringseveraltimesduringtheweekforatleastoneweek AND/ORBrief,limitedorintermittentpsychoticsymptoms(BLIPS)forlessthanoneweek

andresolvingspontaneouslyPredictionofPsychosis

Yungetal1998BritishJournalofPsychiatryMonthsofassessmentNumbernotpsychotic40%madetransitionatsixmonths,50%atoneyearWhatpreventionstrategy?MrazekandHaggerty(1994)havediscussedtheideaofpreventativeinterventionsandidentifiedthreepreventionstrategies.Theseare:·

Universal allofthepopulation·

Selective specificriskfactors Indicated minimal,butdetectable, signsofpsychosisPreventionofpsychosis

McGorryetal2002ArchivesofGeneralN=58Needs-basedintervention.Patientsassignedtothisgroupreceivedneeds-basedsupportivepsychotherapyprimarilyfocusingonpertinentissuessuchassocialrelationshipsandvocationalandfamilyissues.Therapistsalsoperformedacasemanagementrole,providingassistancewithaccommodation,educationoremployment,andfamilyeducationandsupport.Althoughpatientsinthisgroupdidnotreceiveantipsychoticmedication,theycouldreceiveantidepressants(sertralinehydrochloride)ifmoderatetoseveredepressionwaspresentorbenzodiazepinesforinsomnia(usuallytemazepam).Preventionofpsychosis

McGorryetal2002ArchivesofGeneralSpecificpreventiveintervention(SPI)involvedallelementsofNBIand2additionaltreatmentcomponentsHence,SPI,incommonwithNBI,aimedtotreatfeaturesalreadymanifestand,inaddition,toreducetheriskofprogression.Thefirstadditionalcomponentwasadministrationof1to2mgofrisperidonedailyfor6months,andthesecondwasmodifiedCBT.Risperidonetherapywascommencedat1mg/dandincreasedtoandheldat2mg/dprovidedthatnoadverseeffectswereexperienced.Ifadverseeffectsoccurred,thedosagewasreducedto1mg/d.Antidepressantsorbenzodiazepineswereagainusedwhenappropriate.Preventionofpsychosis

McGorryetal2002ArchivesofGeneralCognitivebehaviortherapywasconductedaccordingtoamanualdevelopedbyus.Theoverallaimsweretodevelopanunderstandingofthesymptomsexperienced,tolearnstrategiestoenhancecontrolofthesesymptoms,andtoreduceassociateddistress.ThesestrategiesweredrawnfrommainstreamCBTfornonpsychoticdisordersand,whereappropriate,byadaptingpsychologicaltechniquesthatareusefulinmoreestablishedpsychoticdisorders.Thefollowingmoduleswereofferedflexibly:StressManagement,Depression/NegativeSymptoms,PositiveSymptoms,andOtherComorbidity(includingsubstanceabuse,obsessive-compulsivefeatures,andsocialanxiety).Preventionofpsychosis

McGorryetal2002ArchivesofGeneralPsychiatryMonths%makingtransitiontopsychosisPRIMEClinicMcGlashanTH,MillerTJ,ZipurskyRB,etal.Interventionintheschizophrenicprodrome:thepreventionthroughriskidentification,management,andeducationinitiative.ProgramandabstractsoftheAmericanPsychiatricAssociation156thAnnualMeeting;May17-22,2003;SanFrancisco,California.AbstractS39B.McGlashanTH,ZipurskyRB,PerkinsD,etal.ThePRIMENorthAmericarandomizeddouble-blindclinicaltrialofolanzapineversusplaceboinpatientsatriskofbeingprodromallysymptomaticforpsychosis.I.Studyrationaleanddesign.SchizophrRes.2003;61:7-18.MillerTJ,ZipurskyRB,PerkinsD,etal.ThePRIMENorthAmericarandomizeddouble-blindclinicaltrialofolanzapineversusplaceboinpatientsatriskofbeingprodromallysymptomaticforpsychosis.II.Baselinecharacteristicsofthe"prodromal"sample.SchizophrRes.2003;61:19-30.

PrimeStudyAdouble-blindcomparisonofolanzapinewithplaceboProdromalsymptomsweremeasuredbytheSOPSN=60,andthemedianagewas16years65%males93%ofthepatientshadmildbutdefinablepsychoticsymptoms(attenuatedsymptoms)TheaverageGAFwas42.Thedoseofolanzapineincluded5,10,and15mgstrengths.At1year,15ofthe60patientsdevelopedafullpsychoticsyndrome.Oftheconverters,8of15convertedwithinthefirstmonthfrombaseline.TransitionRatesDifferenceisnotStatisticallysignificantEDDIE

AsingleblindrandomisedcontrolledtrialToidentifyindicatorsofriskthataccuratelypredicttransitiontopsychosisToexaminetheeffectivenessofacognitivetherapyinterventioninreducingthetransitionrateinat-riskindividualsTodeterminetheeffectivenessofamonitoringinterventioninreducingthedurationofuntreatedillnessandpsychosisshouldtransitionoccurEddieEntryCriteriaAged16-36AttenuatedSymptoms-low-levelhallucinationsorunusualideasBLIPS-‘clinical’psychoticexperiencesthatresolvewithinaweekFamilyhistoryplusdeterioration/casenessSchizotypalPDplusdeterioration/casenessPrimaryCareGuidelinesforIdentificationofFirstEpisodePsychosisAdaptedfromLauner&MacKean(2000)

12.4.0212.4.02EDITIMPACTCMHTCrisisTeamIfimmediateriskSub-threshold/uncertaindiagnosisClearlyfirstepisodepsychosisStudyCriteria

BLIPS (ratingonPANSS)Thoseclientsscoring4+onhallucinations4+ondelusions5+onsuspiciousnessThesesymptomsshouldbepresentforlessthan1weekpriortospontaneousresolution

ATTENUATEDSYMPTOMS (ratingonPANSS)Thoseclientsscoring2or3onhallucinations3ondelusions3-4onsuspiciousness3-4onconceptualdisorganisationThesesymptomsshouldoccurwithafrequencyofseveraltimesperweekandchangeinmentalstatepresentfor1weekEarlyDetection:ProblemsEthicsofinterventionsinpre-psychoticphaseSolutionemployinterventionswithminimalrisks/sideeffectsemployinterventionsthatwillbeusefultothosewhowillneverbecomepsychoticinformedchoiceBentall,R.P.&Morrison,A.P.(2002)Moreharmthangood:Thecaseagainstusingantipsychoticdrugstopreventseverementalillness.

JournalofMentalHealth,11,351-356.

PsychosisisnotnecessarilydreadfulPredictionnotveryaccurate(e.g.60%falsepositives)Sideeffectsofmedication(andcanbefatal)atypicalscommonlyproduceweightgainandsexualdysfunction;diabetes;cardiovascularproblemsEffectsofmedicationondevelopingbrainunknownEarlyDetectionandPrevention

Morrison,A.P.etal.(2002)BritishJournalofPsychiatry,181,supp43,78-84.Effectiveforpsychoticsymptoms(AS)Effectiveforrelapseprevention(BLIPS)Effectiveformooddisordersveryfrequentinprodrome(Birchwood,1996)ProblemlistandgoalsusefulforotherdifficultiesACognitiveModelofPsychoticSymptomsClientassessedbyteamRandomisationMonitoringandPsychologicalIntervention26sessionsofCBTMonitoring12monthlymonitoringsessionsReferralstotheteamIfbecomespsychoticreferasappropriateIfbecomespsychoticreferasappropriateBacktoreferrerBacktoreferrerSuitableBacktoreferrerorotherappropriateservicesNotsuitableStudyDesign Referredforassessment(n=134)

Didnotattend(n=14)Refusedparticipation(n=14)

Assessedforeligibility(n=106)

Excluded(n=46)Notmeetinginclusioncriteria(n=27)Refusedtoparticipate(n=3)Untreatedfirstepisodeofpsychosis(n=12)Receivingantipsychoticmedication(n=4)

Randomised(n=60)

AllocatedtoCT(n=37)

AllocatedtoMonitoring(n=23)ReceivedCT(n=37) ReceivedMonitoring(n=23)

Losttofollow-up(n=4) Losttofollow-up(n=4)

3movedoutofarea 2movedoutofareaDroppedoutofCT(n=3) Discontinuedmonitoring(n=3)Wouldnotengage(n=2)

Analysed(n=35)

Analysed(n=23)Excludedfromanalysis(n=2)Bothreportedhavingbeenpsychoticatbaselineassessment

ReferralSources/PathwaysSecondarycareservices 48PrimaryCarePsychologicalTherapyTeams 29GeneralPractitioners 15UniversityandCollegeCounsellors 14AccidentandEmergencyDepartments 10YouthServices 7Hostels 3SocialServices 3Others 505101520253035Accident&Emerg'y

YouthServices

SecondaryCareGeneralPractitionerss

PsychologyServicesSocialServicesHostelworkersUni/CollegeCounsellorsMisc/Other

SuitabilityandtransitionbyreferralsourceReferralsSuitabilityTransitionBreakdownofpopulationTotaln=58Female18(30%)Male40(70%)Attenuated48(80%)BLIPS6(10%)Family6(10%)EDDIEAsingleblindrandomisedcontrolledtrialCognitiveTherapyvs.TreatmentAsUsualPreliminaryResultsfrom12monthsFollow-upn=2n=5n=7n=2TransitioncriteriaTransitionratein%pergroupn=2n=6PredictorsoftransitionPANSS-definedtransition:cognitivetherapy(B=-3.13;SE=1.42;p=0.028;Exp(B)=0.04)baselinePANSSpositivescore(B=0.41;SE=0.20;p=0.039;Exp(B)=1.50)NNTtopreventPANSS-definedtransitionis6.PredictorsoftransitionPrescriptionofantipsychoticmedicationCT(B=-2.86;SE=1.17;p=0.014;Exp(B)=0.06)NNTforpreventingprescriptionofantipsychoticmedicationis5DSM-IVdiagnosisCT(B=-3.33;SE=1.42;p=0.019;Exp(B)=0.04).NNTforpreventingsomeonefrommeetingDSM-IVcriteriaforapsychoticdisorderis5OurApproachToincreaseawarenessinprimarycareservices,secondarycareservices,voluntarysector,furthereducationandthecommunityIncreasereferralsthrough 1.Trainingforpotentialreferrers 2.Rapidresponse 3.Flexibleapproachtoclient 4.Positive,userfriendlyserviceIntervention-ProcessDeveloptherapeuticrelationshipAssessmentEstablishsharedproblemlistTranslateinto‘smart’goalsFormulationInterventionsderivedfromformulationRelapsepreventionEngagementCollaborative,sharedgoals,prioritisedgoals,SMARTgoalsEarlysuccessDifferentrationalesforeachentryrouteFlexibilityre:venue,time,methodsSocialisewithmodel,focusondistressLanguageProblems...“IamunhappywithwhereIlive.”“IfeelanxiouswhenIleavethehouse.”“Iwanttofindmyrealmother.”“IworryaboutpeoplelaughingatmewhenIgoout.”“Ineedtogetajob.”“Iwantmoremoney.”“Mysisterisnastytome.”“Iwanttostopithappeningtomeagain.”“Iwanttoknowwhatiswrongwithme.”“Ifeeldepressed.”“Ifeelanxious.”“Ineedagirlfriend.”...andgoalsTofindoutwhatalternativeaccommodationisavailableandsendlettersorcontactbyphonethevarioushousingagenciesinordertogetontheirwaitinglists.WhenIgoout,IwouldliketobeabletodistinguishwithmorecertaintyifpeoplearelaughingatmeorwhetherIjustfeelthisisthecase(andpreferablyreducedistressfrom60%to30%).TobegintounderstandifwhatIamexperiencingisthestartofschizophrenia.IfIfeltlessanxiousIwouldliketobeabletoleavethehouseandgotothelocalshopswhenIfeltlikeit(andatleastthreetimesaweek).IwouldliketohaveatleasttwopeoplethatIcandiscussmyfeelingswithCommonThemeslonelinessactivityschedulingsocialanxietylackofconfidantI’mdifferentidentitytraumasealingover-->integrationforBLIPSstress(includingwork-related)sleepdrugsFrameworkoftherapyCognitivetherapymaininterventionHoweveritcanbehelpfultointerweavealternativeinterventionsUseofcasemanagementskillssuchasassistancewithhousing,bills,negotiationswithcollege/employer/neighbours.Crisisinterventionskillsattimessuchasbecominghomeless,traumaticeventsetc.Encouragestrategiestomanagethesecrises.InterventionstrategiesFormulationNormalisationWorkingwithmetacognitivebeliefsGeneratingpossibilitiesforintrusionsSafetybehavioursSelectiveattentionActivityschedulingRelapsepreventionFormulationTheformulationusingtheintrusionsmodel(Morrison2001)isdevelopedwithinsessions1&2.Theaimistomovefromgeneralabstractconcernsthepersonmayhavetomorespecificwaysofunderstandingthem.Oneaimofthisprocessisalsotohighlightoccaissionswhentheirinterpretationsdonotleadtodistress.NormalisationThisusestheexistingbodyofworkfromKingdonandTurkington(1994).Theirstrategyallowsdistressassociatedwithsymptomstobemanagedbynormalisingtheexperience.InourstrategyweusethesameapproachbutmoreinlinewiththeintrusionsmodelweutiliseapaperbyRachmanandSilvadiscussingintrusivethoughts.WorkingatametacognitivelevelThismodelofpsychosisdescribeddirectstreatmenttowardsworkingwithmetacognition.Negativebeliefsregardingthea