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Early intervention and prevention for psychotic disorders in Transitional Age Youth
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Early intervention and prevention for psychotic disorders in Transitional Age Youth

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  1. Early intervention and prevention for psychotic disorders in Transitional Age Youth Cameron S Carter MD

  2. Strategies for Improving Outcome • Understand and treat currently treatment refractory symptoms (cognitive deficits and negative symptoms) • Earliest possible intervention

  3. A B C Never Medicated FE Schizophrenia Patients Show Specific Deficit in Context Processing Related Prefrontal Physiology Non-Schizophrenia FE Psychosis Controls FE Schizophrenia MacDonald, Carter et al 2005 American Journal of Psychiatry

  4. The course of schizophrenia Episodic, w/o interepisode deficits Episodic, w/interepisode deficits ( common) Broad therapeutic window for Prevention/Early intervention Chronic, deteriorating

  5. Serious mental disorders in youth • Schizophrenia, bipolar disorder and serious depressive disorders affect up to 3% of the population • Typical onset 12-25 years (TAY) • Hospitalization, school failure, substance abuse, disability and unemployment, criminalization and incarceration frequent complications • We can significantly improve outcome and prevent these complications with an early intervention approach

  6. Prevention • Primary: Before a disease starts, prevent its onset (e.g. by immunization) • Seconday: after a disease has started but before it has a clinical effect e.g. treating hypertension to prevent cardiovascular disease. Pap smear for cervical cancer • Tertiary: identify and alleviate an established disease at an early stage to prevent complications, improve or maintain functional status e.g. aspirin therapy after heart attack to prevent recurrence

  7. http://earlypsychosis.ucdavis.edu

  8. EDAPT Clinic: Rationale • Duration of untreated psychosis is associated with poor outcome • Early in illness treatment response is robust • Loss of function and treatment resistance follow repeated relapses • Early intervention can improve functional outcome • Tailored treatment pathways and therapies for early treatment and rehabilitation

  9. Summary correlations between duration of untreated psychosis (DUP) and outcomes by follow-up point Marshall, M. et al. Arch Gen Psychiatry 2005;62:975-983.

  10. Odds of no remission in the long vs short duration of untreated psychosis (DUP) groups Marshall, M. et al. Arch Gen Psychiatry 2005;62:975-983.

  11. Perkins et al American J Psychiatry 2005

  12. EDAPT Clinic: 2 “Target” Populations • Early psychosis “first episode” patients • Ultra high risk

  13. First Episode Cohort • 12-45 years of age • Onset within the previous 12 months • Goal is to engage patient (and family/support system) in sustained treatment • Stabilize, and support recovery of function and developmental trajectory

  14. The EDAPT Clinic Clinic Description The EDAPT Clinic provides comprehensive diagnostic and treatment services for children and young adults who have recently developed a psychotic disorder, or who are at high risk for one of these disorders. The goals of the clinic are 1. Early Intervention 2. Prevention of disease-related deficits 3. Prevention of treatment-related side effects 4. Active participation in treatment 5. Progression towards personal, social, and occupational goals • Referral Sources • Sacramento County Mental Health Treatment Center (SCMHTC) • UC Davis Outpatient Psychiatry Clinic • Community Psychiatric Hospitals • NAMI • Family Members • School Psychologists/Nurses • Turning Point Crisis Residential • Sacramento County CAPPS Clinic • UC Davis Counseling Center (CAPS)

  15. The EDAPT Clinic Caucasian African American Latino Asian/Pacific Islander Middle Eastern Clinic Demographics Screened (07/05 - 08/07) 493 Accepted into Clinic 104 Total Number Enrolled 70 First Episode Patients 49 ‘Ultra High Risk’ Patients 21 Age Range of Patients 11-34 Average Age 19 Under 18 46% Working or in School 91% Number hospitalized 10 Ethnic Makeup of Clinic Caucasian 57% African American 24 Latino 7 Asian/Pacific Islander 9 Middle Eastern 3 Sacramento County

  16. Some key first episode treatment issues • Diagnostic uncertainty, symptom based treatment, side effects • Denial of illness, non compliance • Depression, suicidality • Family support • “re-entry”, socialization, stress, advocacy • Individualized pathways to recovery, value of peer groups

  17. Key elements of treatment model • Multidisciplinary treatment team • Rapid response, extensive medical and psychiatric assessment • Setting, may be better outside of CMH setting • Medication management • Individual and group therapy (psychoed, motivational, supportive) • Advocacy (school, vocational, insurance and disability etc) • Multifamily support group

  18. Can we delay the onset of psychosis and prevent functional decline? “Ultra High Risk” strategy: subthreshold psychosis, OR genetic risk or SPD and functional decline predict 20-40% conversion rate Very Early Intervention: Ultra High Risk Cohort

  19. Three Prodromal Risk State Categories • Attenuated Positive Symptom State • Onset or worsening in the past year of (a) paranoid, grandiose, or referential ideas but without full conviction, (b) perceptual disturbances but without certainty of an external source, or (c) vague, circumstantial or tangential communication that is coherent and structured under redirection • Brief Intermittent Psychotic Symptom State • Onset in the last month of transient hallucinations, delusions, and/or thought disorder, lasting less than one hour per day • Genetic Risk and Deterioration State • A decline of 30% or more on the GAF in the past 12 months, AND patient either (a) has a first-degree relative with schizophrenia or (b) meets criteria for schizotypal PD

  20. PACE, PRIME, OPUS and PIER12 month outcome

  21. First hospitalizations for psychosis Greater Portland vs. rest of Maine

  22. Improved Outcomes from Very Early Intervention • Results suggestive from Australian, Danish and U.S. studies BUT • Definitive results will be needed to change public policy in the U.S.

  23. Early Detection and Intervention toPrevent Psychosis (EDIPP)

  24. Earlier Intervention: EDIPP • Funded by a $2 million grant from the Robert Wood Johnson Foundation • 5 sites across the nation • Sacramento City, favored due to diversity, UCDMC favored for its strong community partnerships • Seeks to make history, change public policy • Careful diagnostic assessment, SIPS interview, plus active diagnoses and co-morbidities • TARGETTED pharmacological therapies • PIER model multifamily Psycho education and support groups • supportive therapy, family support and therapy, supported education and employment and advocacy • Research for enhanced risk prediction

  25. Community Partnerships SchoolsSacramento City Unified School DistrictM.M.C. Mejia, PhD; Shelton Yip*UCDavis Counseling & Psych Services Diana Davis; Sandra Zeh*UCDavis MIND InstituteJohn Brown*Sacramento State Univ. CounselingDavid Cordosi Community Based OrganizationsCrossroads Employment ServicesDanny MarquezSacramento Children’s HomeRoy Alexander*African American MH ProvidersDee Bridges; Maurice Dunn*El Hogar MH & Community Service Lisa Soto*La Familia Counseling Center, Inc. Anita Barnes* Southeast Asian Assistance CenterLaura Leonelli*Asian Pacific Community CounselingJudy Fong Heary*Hmong Women’s Heritage AssociationMay Ying Ly*Slavic Assistance CenterRoman Romaso* Sacramento County Mental HealthDirector: Ann Edwards-Buckley*Ethnic Services&Cultural Competence Jo Ann Johnson*Child & Adolescent Services, PediatricsCharles Maas*Child & Family HealthLisa Bertaccini Mental Health AdvocacyNAMI SacramentoHeidi Sanborn*Mental Health Assoc. of SacramentoAndrea*& Marilyn HillermanCA Council of CMH AgenciesRusty Selix*Staglin Family Foundation Garen & Shari Staglin *Indicates Steering Committee Member

  26. Entry Criteria • Ages 12-25 • Brief psychotic episode • Prodromal symptoms or recent deterioration in youth with a relative with a psychotic disorder. • Within City of SacramentoZip Codes:94203-94209, 94211, 94229, 94230, 94232, 94234-94237, 94239, 94240, 94243-94250, 94252-94254, 94256-94259, 94261-94263, 94267-94269, 94271, 94273, 94274, 94277-94280, 94282-94291, 94293-94299, 95812-95838, 95840-95843, 95851-95853, 95857, 95860, 95864-95867, 95887, 95894, 95899 The EDAPT Program

  27. What Happens following Referral? • Phone Screen & Assignment or Referral • Intake Clinical & Cognitive Evaluation • Assignment to Case Management or Family-aided Assertive Community Treatment (FACT) The EDAPT Program

  28. Family-aided Assertive Community Treatment (FACT): Clinical and functional intervention • Rapid, crisis-oriented initiation of treatment • Psychoeducational multifamily groups • Case management and Medical Management using key Assertive Community Treatment methods • Integrated, multidisciplinary team; rapid response; continuous case review • Targeted pharmacological intervention as needed • Supported employment and education • Collaboration with schools, colleges and employers • Substance abuse treatment, as indicated The EDAPT Program

  29. Addressing diversity in EDIPP • Role of community partners in outreach, education, development of materials and MFG design • UCDMC medical interpreting services, for outreach, SIPS and individual patient evaluations and care • Development of culturally tailored MFG groups, partnering with therapists from African American, Latino and Hmong communities • Success would provide strong evidence for the value of the early intervention approach in an increasingly diverse American population

  30. EDAPT/EDIPP Team Robinder Bhangoo MD Kathleen Boyum PhD Cameron Carter MD Jane DuBe LCSW Jong Yoon MD Marjorie Solomon PhD Michael Minzenberg MD J. Daniel Ragland PhD

  31. Contact Information EDAPT Hours: 9:00am – 5:00pm M-F To make a referral, call: 916-734-5331 http://earlypsychosis.ucdavis.edu The EDAPT Program

  32. Support • NIMH • Robert Wood Johnson Foundation • NARSAD • Dean Pomeroy and the School of Medicine • Bob Hales and the Department of Psychiatry

  33. UCD Psychosis Research • Cognitive remediation for FE schizophrenia • Using EEG/ERP and fMRI to enhance early diagnosis • Linking PFF dysfunction to disturbances in memory, attention and language comprehension • Understanding and treating negative symptoms

  34. Dan Ragland PhD Jane Dube MSW Kathleen Boyum PhD Emily Olsen Jong Yoon MD Michael Minzenberg MD Stefan Ursu Michael Buonocore MD PhD Key Collaborators

  35. Translational Cognitive and Affective Neuroscience LaboratoryPsychotic Disorders Research ProgramDepartment of Psychiatry, University of California at Davis