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Preventing psychosis, preventing severe mental illness: The time has come

Preventing psychosis, preventing severe mental illness: The time has come. Early Detection, Prevention and Treatment of Psychosis National Association of State Mental Health Program Directors Annual Meeting December 12, 2005 Washington, D.C. William R. McFarlane, M.D. William Cook, Ph.D.

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Preventing psychosis, preventing severe mental illness: The time has come

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  1. Preventing psychosis, preventing severe mental illness: The time has come Early Detection, Prevention and Treatment of Psychosis National Association of State Mental Health Program Directors Annual Meeting December 12, 2005 Washington, D.C. William R. McFarlane, M.D. William Cook, Ph.D. Donna Downing, MS, OTR/L Mary Verdi, MS. Center for Psychiatric Research Maine Medical Center Portland, Maine University of Vermont

  2. Shortened productive lives Source: Mental Health Report of the Surgeon General

  3. $10 million Lifetime costs for each new case of schizophrenia or disabling and psychotic mood disorder

  4. 25% Proportion of hospital beds occupied and disability payments to people with severe mental disorders

  5. 75% Proportion of people who have one psychotic episode and then develop schizophrenia and disability

  6. 10% Proportion of people with schizophrenia who are gainfully employed

  7. 2-3% Proportion of youth who develop schizophrenia or a disabling, psychotic mood disorder

  8. 12-15% Proportion of people with schizophrenia or a disabling, psychotic mood disorder who commit suicide

  9. Age of onset of disabling mental illnesses

  10. Functioning as an effect of psychotic episodes

  11. Effects of multiple relapses Adapted from Lieberman, J., et al., J Clin, Psychiatry, 1996; 57: 5-9

  12. EMPIRICAL EVIDENCE FOR A RELATIONSHIP BETWEEN A LONG DUP AND A POOR PROGNOSIS: • Johnstone et al. 1986: Many psychotic patients did not get appropriate treatment early, even when they sought help. • Crow et al. 1986: DUP more important for the course than maintenance medication. • Rabiner et al 1986: Long DUP was related to a poor one year outcome. • Wyatt 1991,Opjordsmoen 1991: Earlier treatment – better course.

  13. EMPIRICAL EVIDENCE FOR A RELATIONSHIP BETWEEN A LONG DUP AND A POOR PROGNOSIS:(cont.) • Falloon et al. 1992, 1996: Early treatment – no chronic patients. Earlier detection is possible. • Loebel et al. 1992, Lieberman et al. 1993, Szymanski et al. 1995: A long DUP correlated with a poor course (time to and level of remission). • Haas et al. 1994: A long DUP was related to a slower treatment response.

  14. TIPS; the historical control studyDUP frequency distribution N = 43 DUP; 114 (mean), 26 (median) 173,6 (S.d) N = 49 DUP; 17,1 (mean), 6 (median) 26,3 (S.d)

  15. Biologic risk factors • Genetic risk • 80-85% heritability • Non-genetic biologic risk • Prenatal infections (influenza) • Prenatal toxic exposure (lead) • Obstetrical complications • Traumatic (head trauma, perinatal period to adolescence) • Autoimmune (Rh incompatibility, increasing risk with multiple births) • Nutrition (starvation, omega-3 deficiency) • Heavy cannabis, other psychotogenic drug exposure • Non-heritable genetic risk • Age of father >50; probably natural mutations in spermatogenesis

  16. Early Insults Social and Environmental Triggers e.g. Disease Genes, Possibly Viral Infections, Environmental Toxins Psychosis Increasing Positive symptoms Disability Biological Vulnerability: CASIS Cognitive Deficits Affective Sx: Depression Social Isolation School Failure Brain Abnormalities Structural Biochemical Functional Courtesy Barbara Cornblatt, Ph.D.

  17. Effects of untreated initial psychosis • Being psychotic is a personal disaster and the longer it lasts, the more it can become traumatic and stigmatizing. • Being psychotic reduces cognitive and social function. The longer patients are manifestly psychotic, the greater the risk that they may lose contact with family and friends, fail school, or drop out of work. • The longer the psychosis lasts, the more difficult it may be for the therapist to establish a good therapeutic relationship with the patient.

  18. * p < 0.001 **p = 0.582 G X E interaction: p=0.018 Tienari, Wynne, et al, BJM, 2004

  19. Withdrawal "Oddness" Functional deterioration Social & performance deficits Social deficits Critical comments CD, EOI Anxiety Panic Misattribution High EE Psychosis Illusions Dread Insomnia Anorexia Perceptual distortions Pervasive anxiety Biosocial causal interactions in late schizophrenic prodrome Early prodrome Late prodrome Acuteonset

  20. Portland Identification and Early Referral(PIER) Reducing the incidence of major psychotic disorders in a defined population, by early detection and treatment: Secondary prevention

  21. Greater Portland Population ~315,000 Portland

  22. Project Overview

  23. Professional and Public Education • Reducing stigma • Information about modern concepts of psychotic disorders • Increasing understanding of early stages of mental illness and prodromal symptoms • How to get consultation, specialized assessments and treatment quickly • Ongoing inter-professional collaboration

  24. Youth Education • Public service announcements by mainstream television and health information programs • Interviews and spot announcements by youth television cable network • 2-3 sessions on early warning signs as part of the obligatory 10th grade health curriculum • Widespread distribution of bookmarks and posters throughout catchment area schools, colleges, bookstores • Art and literature contest • Major publicity events during Mental Illness Awareness Week • Youth oriented website: www.preventmentalillness.org

  25. Welcome Mental illness Getting help About PIER Resources News Contact

  26. Family practitioners College health services Mental health clinicians Military bases and recruiters Pediatricians PIER Team School teachers, guidance counselors, nurses, social workers Clergy Emergency and crisis services Creative Marketing& Design Large employers General Public

  27. College health services Family practitioners Mental health clinicians Military bases and recruiters Pediatricians PIER Team School guidance counselors, nurses, social workers Clergy Emergency and crisis services Large employers General Public

  28. Clinical Strategies

  29. Signs of prodromal psychosisSchedule of Prodromal Syndrome (SOPS), McGlashan, et al A clustering of the following: 1. Changes in behavior, thoughts and emotions, with preservation of insight, such as: • Heightened perceptual sensitivity • To light, noise, touch, interpersonal distance • Magical thinking • Derealization, depersonalization, grandiose ideas, child-like logic • Unusual perceptual experiences • “Presence”, imaginary friends, fleeting apparitions, odd sounds • Unusual fears • Avoidance of bodily harm, fear of assault (cf. social phobia) • Disorganized or digressive speech • Receptive and expressive aphasia • Uncharacteristic, peculiar behavior • Satanic preoccupations, unpredictability, bizarre appearance • Reduced emotional or social responsiveness • “Depression”, alogia, anergia, mild dementia

  30. Signs of prodromal psychosis • 2. A significant deterioration in functioning • Unexplained decrease in work or school performance • Decreased concentration and motivation • Decrease in personal hygiene • Decrease in the ability to cope with life events and stressors • 3. Withdrawal from family and friends • Loss of interest in friends, extracurricular sports/hobbies • Increasing sense of disconnection, alienation • Family alienation, resentment, increasing hostility, paranoia

  31. Family-aided Assertive Community Treatment (FACT): Clinical and functional intervention • Rapid, crisis-oriented initiation of treatment • Psychoeducational multifamily groups • Case management using key Assertive Community Treatment methods • Integrated, multidisciplinary team; outreach PRN; rapid response; continuous case review • Supported employment and education • Collaboration with schools, colleges and employers • Cognitive assessments used in school or job • Low-dose atypical antipsychotic medication • 10-20 mg aripiprazole, 2.5-7.5 mg olanzapine, 0.25-3 mg risperidone • Mood stabilizers, as indicated by symptoms: • SSRIs, with caution, especially with aripiprazole and/or a family history of manic episodes • Mood stabilizing drugs: lamotrigine 50-150 mg, valproate, 500-1500mg, lithium at therapeutic doses by blood level 0.6-1.2

  32. Key clinical strategies in family intervention specific to prodromal psychosis • Strengthening relationships and creating an optimal, protective home environment: • Reducing intensity, anxiety and over-involvement • Preventing onset of negativity and criticism • Adjusting expectations and performance demands • Minimizing internal family stressors • Marital stress • Sibling hostility • Conceptual and attributional confusion and disagreement • Buffering external stressors • Academic and employment stress • Social rejection at school or work • Cultural taboos • Entertainment stress • Romantic and sexual complications

  33. PIER: Twelve month outcomes Preliminary data for SOPS-positive prodromal cases from the first 36 months of intake: n = 65 Intake: May 7, 2001- May 6, 2004 12-month outcome: May 7, 2002- May 6, 2005

  34. PIER referral sources

  35. Screening and treatment entry

  36. Demographics: Referred population and SOPS+ treated sample

  37. Treated cases converting to psychosisScoring 6 on SOPS, at any time, year 1n=55 • Cases not converted 47 85.5% • Cases converted, 1-6 days 2 3.6% • Cases converted, 7-30 days 2 3.6% • SOPS conversions* 1 1.8% • Schizophrenic disorder 3 5.5% • Intent-to-treat (n=65)** 14 21.5% *Scoring at 6 for 4 days/week for >30 days **Assuming 40% conversion of cases refusing or dropping out

  38. PACE, PRIME and PIER12 month outcome

  39. SOPS scores at baseline and 12 months p<.001 p<.001 p<.001 p<.001 n=50

  40. GAF: Baseline and 12 months n=50; t=5.91; p=.001

  41. Functional outcomes, last year of intake (treated n = 16)

  42. Components of expressed emotion: Prodromal vs. chronic phase SAS-III, Rejection and Emotional Over-involvement subscales All differences, prodromal vs. chronic: p<0.01

  43. Correlations of mothers' level of EE with duration of prodrome

  44. Differences between treated prodromal and post-psychotic states Prodromal young persons have manifested: • Maintenance of insight (prevention of loss) • Continued dysphoric/ego-dystonic response to prodromal/psychotic symptoms • High acceptance of, and adherence to, treatment • Low rates of substance abuse • More open to discontinuing heavy drug and alcohol abuse • Less resistance to family inclusion by patient • Stronger family involvement • Higher motivation to continue schooling and/or work • More trusting and grateful therapeutic relationships • Higher sensitivity to treatments • Higher likelihood of improving course of functioning

  45. First admissions for psychotic episodes:Rate differences, Portland vs. rest of Maine 1995-2000 vs. 2001-2003

  46. First admissions for psychotic episodes: State of Maine and Portland PIER Starts

  47. First admissions for a psychotic episode: Differences in rates Portland minus Rest of Maine PIER Starts PIER Starts

  48. First admissions for schizophrenia: State of Maine and Portland

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