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Eion Killackey delivered the presentation at the 2014 Young People at Risk Forum. The 2014 Young People at Risk Forum reviewed the challenges and solutions surrounding intervention programs around topics such as suicide prevention, substance abuse, mental health, education, employment and housing. Additionally, the forum focused on culturally competent care and care within Aboriginal communities. For more information about the event, please visit: http://www.informa.com.au/yprisk14
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Early treatment of psychosis
Eóin Killackey
Associate Professor
Orygen Youth Health Research Centre
DEVELOPMENT AND MENTAL ILLNESS
Youth as a distinct developmental phase
Adolescence begins earlier and finishes later than ever
Brain development dynamic from puberty until mid 20s
However the phase is culturally specific
Key developmental tasks
Transition more complex and desynchronous
Cohesive yet heterogeneous youth culture
Generational and cohort effects (Wyn)
Disease Incidence across
Lifespan
Risk factors for mental illness
HOW DOES MENTAL ILLNESS DEVELOP? – TWO POSSIBILITIES
Psychosis Risk Syndrome
Bipolar Risk Syndrome
Tenacious Depression Syndrome
THE GRAND DSM V RAILROAD
Clinical Staging
psychosis
depression mania
schizophrenia
depression mania bipolar
disorder
psychosis
STAGING MODEL AND INTERVENTION
Need for a staging model in mental illness
• Prevailing view
– Psychosis arrives due to a combination of
• Genes
• Environment
• Psychological factors
• Leads to a particular approach to treatment
• Other areas of chronic illness medicine don’t take this approach
Staging proposal
• Mental illness develops in stages
• If we can describe these stages we can potentially understand the development of illness better and treat more efficiently
• Significant disability and social exclusion could be avoided
Benefits of staging proposal
• We can start to examine the development of illness and identify earlier targets
• According to the Staging Model risks must be lower if treatment occurs earlier and treatment for ultimately more serious/exit syndrome more effective in longer term
Subthreshold and Threshold
Disorder…… Stage Definition Referral sources Potential interventions
0 Increased risk of psychotic or severe
mood symptoms but currently
asymptomatic
First-degree young relatives of
probands
Improved mental health literacy
Family and drug education
Brief cognitive skills training
1a Mild or non-specific symptoms, mild
functional change or decline
Screening of youth populations
Referral by primary care physicians
or school counsellors
Formal mental health literacy/eHealth
Problem solving and support
Family psychoeducation
Substance misuse reduction
Exercise
1b
Ultra-high risk: Moderate but
subthreshold mood/positive/negative
symptoms with moderate
neurocognitive changes and
functional decline (GAF < 70)
Referral by educational agencies,
primary care physicians, emergency
departments, welfare agencies
Formal CBT/CM
Family psychoeducation
Substance abuse reduction
Omega-3 fatty acids
Atypical antipsychotics?
Antidepressants, mood stabilizers?
2
First episode of full-threshold
disorder with moderate to severe
symptoms, neurocognitive deficits
and functional decline (GAF 30 - 50)
Referral by primary care physicians,
emergency departments, welfare
agencies, specialist care agencies,
drug and alcohol services
Formal CBT/CM
Family psychoeducation
Substance misuse reduction
Atypical antipsychotics
Antidepressants or mood stabilizers
Vocational rehabilitation
Insel, T. (2010) Nature
Only 13% of young men and 31% of young
women access the mental health care they need
access
can be
difficult
SOME COMMONSENSE REASONS FOR EARLY INTERVENTION
Symptom-Disability Gap in Early
Psychosis
Providing access during usually prolonged phase when major psychosocial disability develops (Agerbo et al 2003)
Disability
Gibb et al BJPsych 2010
“Psychiatric disorder during young adulthood was
common, with 50.1% of participants experiencing at least
one psychiatric disorder (depression, anxiety disorder or
substance dependence) between the ages of 18 and
25.”
“Many participants experienced more than one episode of
psychiatric disorder during young adulthood. Of those
who experienced any psychiatric disorder during young
adulthood, 54.5% experienced two or more episodes of
disorder.”
Potential Impact of Early Intervention Strategies
Reintegration: Work and school
• Age of onset
• Disruption of education • Only 32% with psychosis complete high school
• Maximum of 62% in other mental illnesses
• Compares to 78% for same age peers
• Poor transition to employment • 50% unemployed at outset of illness in psychosis
• Between 20% and 50% in other illnesses
• Rises quickly in psychosis to nearly 90%
• Rapid transition to benefits
• Youth Allowance, Newstart, Disability Support Pension (DSP)
Why are employment and education an issue for young people with mental illness?
Total cost of illness
Cost associated with unemployment
% of total
Australia (2001)
$1.8 billion $866 million 48%
Australia (2010)
$4.9 billion $2.17 billion 52%
USA (2004) $61 billion $32 billion 52%
Costs of people with schizophrenia not working
Employment is healthy (in general)
•The literature describes open employment as the most frequently-identified long-term goal of people with mental illness ( Rogers et al, 1991; Secker et al, 2001)
People with psychosis don’t want to work
In First Episode?
Ramsay 2011 (USA)
• Employment (53%)
• Education (38%)
• Relationships (35%)
• Housing (25%)
• Health (15%)
Iyer 2011 (India)
• Work (38.2%)
• Interpersonal (20.6%)
• School (16.2%)
• Symptom relief (10.3%)
• Living Situation (7.4%)
• The top three life domains that people with psychotic illness in Australia want to address are: • Financial matters;
• Loneliness/social isolation, and;
• Lack of employment
• Ahead of symptom management, managing physical health and the side effects of medication
SHIP study findings
Barriers
Barriers to work
18%
14%
14%
12%
12%
11%
11%
4%
2% 1% 1%
Barriers to work
Lack experience
Other
Qualifications/skills
Health/Disability
Too many applicants
Transport
Lack of desired jobs
Unsuitable hours
Discrimination
Employers think I'm too young
Language
•N=48 •7 on benefits at time of admission •30 others initiated receipt of benefits with median time 7 months from admission •Only 2 stopped receiving benefits over a 5 year follow up •At 5 years 35/48 (73% continued to receive benefits)
• Ho B-C, Andreasen N, Flaum M: Dependence on public financial support early in the course of schizophrenia. Psychiatric Services 1997; 48(7):948-950
Welfare benefits and first episode psychosis
Pensions
DSP exit points 2013
• Of people with psychiatric and psychological disabilities accessing the most intensive employment assistance only 26% achieved a placement and only 14% achieved 13 weeks of employment.
The disability employment system for people with mental illness
Stigma
The power of anticipated discrimination
Thornicroft et al., 2009 Lancet
Mismanifested care
•“we must have the opportunity to try and to fail and to try again…Professionals must embrace the concept of the dignity of risk and the right to fail if they are to be supportive of us”
•Deegan, 1996
Employment
What do we know works?
•Described by Becker & Drake (2003)
•8 core principles (updated in Swanson et al., 2011):
1. Service is open to any person with mental illness who wants to look for work
2. The IPS program is integrated with the mental health treatment team
3. Focussed on competitive employment as an outcome
4. Personalised benefits planning/counselling is provided
5. Job searching commences directly on entry into the program & is not determined by measures of work-readiness or illness variables
6. IPS worker develops relationships with employers based upon client interests
7. Potential jobs are chosen based on consumer preference
8. Support provided in the program is time-unlimited, continuing after employment is obtained, & is adapted to individual needs
Individual Placement & Support (IPS)
Competitive Employment Rates in 16 Randomized Controlled Trials of Supported Employment
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
96
NH
(IPS)
07
Aust
(IPS)
94
NY
(SE)
07
IL
(IPS)
04
CT
(IPS)
05
HK
(IPS)
06
SC
(IPS)
06
MA
(ACT)
99
DC
(IPS)
07
CA
(IPS)
95
IN
(SE)
07
EUR
(IPS)
06
QUE
(IPS)
00
NY
(SE)
97
CA
(SE)
02
MD
(IPS)
Supported Employment Control Control 2
In FEP (Killackey, Jackson & McGorry, BJP, 193, 114-120)
Recruited 41 people with first episode psychosis and randomly allocated to groups
Treatment as usual (n=21) Individual placement and support + treatment as usual (n=20)
Baseline assessment: SCID, CESD, QOL, BPRS, Job history, SANS, SOFAS
6 month assessment: SCID, CESD, QOL, BPRS, Job history, SANS, SOFAS, Indiana Job satisfaction scale, work related variables e.g. $ or hours per week etc.
IPS (n=20) TAU (n=21) Sig.
Jobs 13 2 P<0.000
Courses 4 4 ns
Weeks worked 5 0 P=0.021
Pay 2432 0 P=0.012
Benefits (change) -30% 0% P=0.025 P=0.317
Rinaldi, et al., 2010 International Review of Psychiatry
•In the IPS studies, 69% who received an intervention had a positive outcome compared with 35% in control groups
•Outcomes sustained up to 18 months in RCT and 24 months in clinical practice
Overall outcomes
Education
Employment’s foundation
People with schizophrenia % employed (n=380)
(Waghorn, 2003)
SIGNIFICANCE OF SCHOOL QUALIFICATIONS
Course of Illness <yr12 >yr12
Single episode, good recovery 16.7 66.7
Multiple episodes, good recovery 9.1 29.4
Multiple episodes, partial recovery 8.2 27.9
Chronic illness, little deterioration 14.3 12.1
Chronic illness, clear deterioration 1.5 21.7
Education intervention for people with mental illness
•19 participants 15-20 years of age
•6 month intervention
•At baseline 11 enrolled and not attending
•8 not enrolled neither “earning or learning”
•Outcome: 18 enrolled and either attending or completed
•1 neither earning or learning
Education Intervention Study
Transition: education to employment
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