What is going on in the world of Early Psychosis?

1. What is going on in the world of Early Psychosis? Rob Wolf Bruce Neben Ryan Melton http://www.iepa.org.au

2. DSM V & Psychotic Disorders • Dropping Schizophrenia subtypes • Includes shared psychotic disorder • Adds catatonia specifier • Adding Psychosis Risk Syndromes • Attenuated Psychotic Symptoms Syndrome • Moving away from “prodrome”. • http://www.dsm5.org/Pages/Default.aspx

3. Structure Interview for Psychosis Risk Syndrome SIPS 5.0! McGlashan, Walsh, Woods (2/17/10) • Aims • Rule out past and current psychosis • POPS (presence of psychotic symptoms at 6 on SOPS-scale of psychosis risk syndromes. • Rule in one or more of 3 types of At risk syndromes • BIPS (Brief Intermittent Psychotic State) • Attenuated Positive Symptom State (APSS) • Genetic Risk & Deterioration (GRD) • Rate severity of current at risk syndromes. • Major changes • Rule out criteria emphasized • Emphasis on more objective GAF.

4. Effect of Antipsychotic Medication Alone vs. Combined with Psychosocial Intervention on Outcomes of Early-Stage Schizophrenia (Guo et al. 2010) • 1 year RCT of 10 sites with 1268 individuals (China). • Tx group received meds, family psychoeducation (not mfg), skills training, CBT. • Outcomes: • Tx group lower drop out • Tx group greater improvement in insight, social function, ADL’s, quality of life, employment & education.

5. Clinician Integrity In MFGs: Psychometric Properties and Relationships with Schizophrenia Client and Caregiver Outcomes. (McDonell et al. 2007) • Clinical trial of 106 individuals in their families to determine if integrity to model predicted outcome. • Results indicated those who received high integrity to model had lower rates of psychiatric symptoms when compared to those who received lower/moderate integrity. • No difference in caregiver distress. (Did not measure common mfg outcomes of EE and communication).

6. Neuroprotective Effects of Cognitive Enhancement Therapy Against Gray Matter Loss in Early Schizophrenia. (Eack et al. 2010) • 2 year RCT of 53 early course schizophrenia individuals. • Tx group received intensive CET in addition to medications and supportive therapy. • Outcomes: • Tx group had greater preservation of gray matter in left hippocampus, parahippocampul gyrus, and fusiform gyrus. • Tx group had significantly greater gray matter increase in amygdala.

7. Findings from the The North American Prodrome Longitudinal Study (NAPLS)

8. The largest longitudinal study on psychosis • Study of 2 ½ years after initial assessment • A consortium of longitudinal studies from 10 major universities • All NIMH funded • All studies contribute to a common database

9. Affective psychosis may share a prodrome with schizophrenia spectrum disorders • Conversions to affective psychosis were in the minority- 10% • DSM IV diagnosis is unstable in first episode and is not a good predictor of future diagnoses

10. Prodrome- social and role functioning are impaired • Role functioning is malleable and can be impacted • Social impairment is stable and is difficult to impact

11. Overall risk of conversion to psychosis is 35% • Decelerating trend of conversion • Rate of conversion is highest in the first 6 months- 13% • 7 to 12 months 9% • Then 5% • 25 to 30 months- 2.7%

12. Most important prodromal factors predicting conversion to frank psychosis • Genetic risk with functional decline • Unusual thought content • Suspicion/paranoia • Social functioning • Substance abuse

13. “I read the news today, oh boy” • The most widely used illicit drug in the world, youngest age of initiation, potency and use has increased since 1970’s • In first-episode psychosis, rates of cannabis abuse range from 15% to 65% • Most common reasons for use: reduce boredom, something to do with friends, to improve sleep • Use can result in transient psychosis, mania, panic, depression, and cognitive impairment • Cognitive deficits from heavy usage can take 28 days to several months to resolve

14. Are you really listening to this guy?

15. Does cannabis worsen symptoms in people with schizophrenia? yes • D’Souza (2005) 0, 2.5 mg, 5 mg of THC to clinically stable SCZ and controls • 80% SCZ group had a brief, modest increase in their typical positive symptoms/ 35% of controls experiences psychosis • At 5 mg there was significant cognitive impairment in SCZ group and controls at 5 mg experienced cognitive impairment similar to baseline cognitive impairment of the SCZ group

16. Does cannabis cause a persistent psychotic disorder? maybe • Andreasson’s famous Swedes study (1969-1970/ 45K conscripts) • 2.4 X higher than nonusers • 6 X higher if used >50 X • Arseneault and Dunedin study (1972-73/ 1,037/ 26 years) • 3X between 15-18 lead to increased risk • If age 15, 10% SCZ dx vs. 3% controls • Van Os (2002/ 4,104/ 3 years) • Compared nonpsychoticvs psychotic disorders using THC and found psychotic sxs. Increased in a dose dependent nature (13% vs. 50%)

17. What are some opponents of the causal theory? • Despite the significant increase in THC usage and the lower age of exposure, the incidence of SCZ has not changed • There is striking uniformity in the incidence of SCZ in different cultures though the rates of THC use vary widely • Most people with SCZ do not use THC (25%) • Most people who use THC do not develop SCZ (7%) • SCZ is believed to be a neurodevelopmental disorder that begins in childhood, well before THC use begins • The self-medication hypothesis has been repeatedly disproven • THC use is linked to depression, cognitive impairments, negative symptoms, anxiety • Most studies show that THC usage precedes the onset of psychosis • Most studies show reasons for THC usage are not associated with symptoms of SCZ

18. How might cannabis cause a psychotic disorder? • Endocannabinoids play an important role in neurodevelopment which is occurring into mid 20’s, exogenous cannabinoids interfere with that system • THC increases dopamine release in the frontal lobe via binding to a CB1 receptor • Individuals with SCZ have a greater density of CB1 receptors in the prefrontal cortex. • Elevated levels of anandamide, an endogenous cannabinoid receptor agonist, is found in the CSF of people with SCZ

19. Irregardless…..

20. conclusion • Cannabis can induce a transient SCZ-like state with positive, negative, and cognitive symptoms • These symptoms may be greater in magnitude and duration for people with SCZ • Early and heavy exposure may result in a psychotic disorder • Yet, the increase in use, the use of more potent forms, and the earlier age of exposure has not resulted in an increase in the rates of SCZ • Most people who use cannabis do not develop SCZ, most people with SCZ do not use cannabis.

21. PUFA (fish oil) • FA reduce free radicals, improve antioxidant defense, reduce cell injury and stabilize the cell membrane • Stabilize the serotonergic and dopaminergic systems • Reduced levels of FA in individuals with SCZ • Four controlled trials of FA supplementation that has shown beneficial effects in patients with SCZ • Randomized, placebo-controlled trial of 1.2 g of w-3 FA for 12 weeks • 4.9% of treated group transitioned to psychosis vs. 27.5 % of the placebo group • PUFA significantly reduced positive and negative symptoms and improved functioning • Results were sustained after one year

22. Recovery

23. Can people with schizophrenia recover? • DSM III (1980) • “a complete return to premorbid levels of functioning in individuals with schizophrenia is so rare as to cast doubt upon the accuracy of the diagnosis.” • DSM IV (2000) • Complete remission… is not common in this disorder.

24. Elyn Saks • Vanderbilt University • Oxford University • Yale Law School • USC Law Professor and Associate Dean

25. Elyn Saks • Vanderbilt University • Oxford University • Yale Law School • USC Law Professor and Associate Dean • Person with schizophrenia

26. How some people with schizophrenia thrive • Shirley Glynn • Ellen Saks • Etc • What Coping Strategies do high functioning people with schizophrenia use?

27. Coping Strategies of high functioning people with schizophrenia • Take medicine as prescribed • Staying healthy • Exercise, regular sleep, eating healthy foods • Spiritual activities • Having pets or not living alone • Controlling the amount of stimulation in the environment • An attitude of perseverance- Hope

28. Coping Strategies of high functioning people with schizophrenia Taking care to avoid: • Drugs and Alcohol • Traveling • Crowded social situations • Isolation

29. Why do we tend to have a discouraging opinion about recovery?

30. Why do we tend to have a discouraging opinion about recovery? • The clinicians illusion • Only 1/3 of people with schizophrenia come to treatment About 50% of people with schizophrenia have good outcomes

31. What is a “good outcome?” Recovery: “People are are able to live, work, learn and participate fully in their community. For some the ability to live a fulfilling and productive life despite a disability….” The President’s New Freedom Commission on Mental Health

32. Does the developing world lead the way? Generally better outcomes in the developing world, especially Nigeria and India • A greater percentage of people with schizophrenia in the developing world work and marry. • In India 67% marry • Results attributed to increased family and community support and lack of financial disincentives

33. Where does this leave us? • Recovery from schizophrenia is not only possible, but probably common • Family and community support is critical • Self-care is critical • While some people will not have positive outcomes, many can • What have we learned today that can help us improve outcomes and support recovery?