Introduction to At-Risk Mental States Why are we doing this work?

Introduction to At-Risk Introduction to At-Risk Mental States Mental States

Why are we doing this work?Why are we doing this work?

Introduction

What is the rationale behind detecting psychosis early – is there a need?

What do ‘at-risk’ clients look like

Thinking about Services

A very brief history…

Psychosis: The Early Course

Adapted from Larsen et al., 2001

premorbid phase very early symptoms psychotic symptoms

The typical course of psychosis

Psychosis

Treatment & Recovery Relapse?





Psychosis


“DUP”





Psychosis


“DUP”

Early Intervention after onset of psychosis (EIS)

Tertiary Prevention





Psychosis


“DUP”

Early Detection & Intervention in the at-risk phase (ED:IT)

Early Intervention after onset of psychosis (EIS)

Tertiary Prevention

Is there a need..?

‘Every year across the UK about 7,500 people will develop a first episode of psychosis, onset usually occurring in young people…

…this can lead to long term problems, sometimes life long, which leave people on the margins of society, struggling to maintain relationships, or get a job, an income or a home.

As many as one in ten die by suicide, often within the first

five years, and their families, friends and communities often carry huge burdens of care.’

(report on early detection & intervention - Parker et al 2007)

Is There a Need? Duration of Untreated Psychosis (DUP) remains approx. one year

after onset of psychosis

Poorer outcome related to length of untreated psychosis (Drake et al.

2000; Yung et al. 2003)

Significant disability associated with prodrome (Yung et al., 1996)

Between 5 -15% of individuals with Schizophrenia will commit

suicide – most within the first six years of psychosis (Melle et al. 2006)

Often the individual and family are in distress

Other Positives to earlier detection

Intervening early may improve engagement with services

(when insight is intact)

Reduce the trauma of hospitalisation & use of M.H. act

Intervening early may reduce psycho-social deterioration

Other Positives to earlier detection

Intervening early may improve engagement with services

(when insight is intact)

Reduce the trauma of hospitalisation & use of M.H. act

Intervening early may reduce psycho-social deterioration

The possibility to PREVENT psychosis in

vulnerable young people??

What do at-risk clients look like?What do at-risk clients look like?

Employ PACE ‘at-risk’ criteria to identify: Familial risk plus reduced level of functioning in past yr or Attenuated psychotic symptoms or Brief, Limited, Intermittent Psychotic Symptoms Aged 16-35 years

Plus: Evidence of distress & difficulty

EPOS : an international prospective study of transition to EPOS : an international prospective study of transition to psychosis in individuals at ‘ultra high risk’ psychosis in individuals at ‘ultra high risk’

European Prediction of European Prediction of Psychosis StudyPsychosis Study

Cologne

Berlin

Amsterdam

Turku

Birmingham

Manchester

EPOS Demographic Data 1

Sample size 246

Age (mean ± SD) 23.0 ± 5.2

Gender (m : f in %) 56.1 : 43.9

Years of schooling (incl. university) (mean ± SD)

13.5 ± 2.8

Current work situation (n [%])

Full/part time work 55 [22.3]

In full time education 99 [40.2]

Unemployed 36 [14.6]

Unable to work (sickness/disability) 43 [17.5]

Other 10 [4.0]

EPOS Demographic Data 2

Current Partnership Status n %

Single 200 [81.3]

Married

Cohabiting

10

34

[4.1]

[13.8]

Separated/Divorced 2 [0.4]

Current Living Situation n %

Lives alone 61 [24.8]

With another person 29 [11.8]

In a family 123 [50.0]

Flat share 30 [12.2]

In an institution 3 [1.2]

EPOS Demographic Data 3 – it‘s not only about psychosis1° relative with psychotic disorder (n[%]) 30 [12.2]

2° relative with psychotic disorder (n[%]) 17 [6.9]

Schizotypal personality disorder (SIPS) (n[%]) 33 [13.4]

Pre- or perinatal complications (n[%]) 39 [15.9]

Any depressive disorder (n[%]) 120 [48.8]

Any bipolar disorder (n[%]) 19 [7.7]

Any anxiety disorder (n[%]) 118 [48.0]

Any substance abuse disorder (n[%]) 100 [40.8]

GAF score (mean ± SD) 51.0±11.8

BDI (depression - mean ± SD) 20.3±10.9

I don't have any thoughts of killing myself

I've thoughts of killing myself, but I won't carry

them out

I would like to kill myself

I would like to kill myself if Ihad the chance

0.0% 10.0% 20.0% 30.0% 40.0% 50.0%

Percent

Participants with Suicidal Ideation at Baseline (BDI) - 55% n=232

Cannabis use of high risk patients EPOS Study sites (n: 246)

Study sites EPOS lifetime recent-regular use

> 5 times during life

Last year ≥ once a month

Cologne, Berlin 51.6 % 31.0 %

Birmingham, Manchester

47.2 % 34.0 %

Amsterdam 43.2 % 40.9 %

Finland 20.0 % 9.3 %

Total 42.0 % 28.6 %

Transition rate high risk patients EPOS study centres (n=246)

Study sites EPOS proportion %

Amsterdam 19/47 40.4 %Cologne, Berlin 12/91 13.2 %Birmingham, Manchester

6/53 11.3 %

Turku 6/55 10.9 %

Total 43/246 17.5 %

EPOS Transition Rates(To September 2006)

Total number of transitions 41

Transition rate (ref. to baseline)

12 months (n = 246) 31 (12.60%)

18 months (n = 246) 39 (15.04%)

Transition rate (ref. to risk set)

12 months (n = 199) 31 (15.57%)

18 months (n = 170) 39 (22.94%)

StudyStudy N at N at baselinebaseline

ObservationObservation

Period Period (months)(months)

Transition rateTransition rate

EPOS 2461218

12.6 15.04

Broome et al. 2005 58 ? 10.3

Mason et al. 2004 74

>12, 26.3 ± 9.2

50%

McGlashan et al. 2006

6029 (Plc)

17

121224

26.7 37.9 29.4%

Miller et al. 2002 13

6 12

46.2%53.8%

Morrison et al. 2004

6023

(TAU)12

11.7 21.7

Nordentoft et al. 2006 (SD ICD-10)

7937 (ST)

12 (24)16.527.0

Pantelis et al. 2003 75

1824

24%31%

Yung et al. 2004104

(49+55)612

27.9% 34.6%

Yung et al. 2006 119 6 10.1%

Treatment methods measured in EPOS included:

- Medication (sorted by type e.g. Antipsychotic; Anxiolytic; Antidepressant..

- Psychological Therapy (sorted by type e.g. CBT; Psychotherapy..

- Monitoring (telephone / face to face etc)

- Group Therapies (e.g. for Social Anxiety)

- Family Interventions (e.g. Psychoeducation)

D Fin NL UK Mean

Any psychotherapy (%) 41 62 36 95 59Any meds (%) 36 75 32 50 43Neither (%) 41 16 57 - 28

Medication and Psychological Therapy

D Fin NL UK Mean

Any psychotherapy (%) 41 62 36 95 59Any meds (%) 36 75 32 50 43Neither (%) 41 16 57 - 28 SIPS+ 8.7 9.1 11.6 10.2 9.7


D Fin NL UK Mean

Any psychotherapy (%) 41 62 36 95 59Any meds (%) 36 75 32 50 43Neither (%) 41 16 57 - 28 SIPS+ 8.7 9.1 11.6 10.2 9.7 Transition rate (%) 7.7 10.9 29.8 11.9 14


D Fin NL UK Mean

Any psychotherapy (%) 41 62 36 95 59Any meds (%) 36 75 32 50 43Neither (%) 41 16 57 - 28 SIPS+ 8.7 9.1 11.6 10.2 9.7 Transition rate (%) 7.7 10.9 29.8 11.9 14Expected Transition without Intervention: 35 – 54% (SIPS/CAARMS)


Treating ‘at-risk’ clients Confusion as to how to treat this cohort – not

‘psychotic’ but very unwell… Little evidence as to the relative effectiveness of

medication / psychological therapies / case management

Guidelines for treatments for HR group developed by International Early Psychosis Association (2005) but not consistently adopted by local services

Early Detection Report (Parker et al 2007) – suggested guidelines

Developing a Service Approach

Early DetectionEarly DetectionEarly DetectionEarly Detection

Education, Education, Awareness-Awareness-

raising, Trainingraising, Training



Accurate- assessment, Evaluation

Accurate- assessment, Evaluation

Engagement, Appropriate client/family Treatments








Stigma & the media

Stigma – Public Attitudes to Mental Illness

83% agreed society needs to adopt a more tolerant attitude

89% agreeing that society has a responsibility to provide people with the best possible care

74% agreed that mental illness is an illness like any other

20% said there is something about people with mental illness that makes it easy to tell them from normal people

Department of Health Survey (2003) : http://www.doh.gov.uk/public/england.htm (1897 adults, 16+)

Stigma – Public Attitudes to Mental Illness 2

25% agreed that people with mental illness should be excluded from public office and 16% said they should never be given any responsibility

Only 21% of respondents agreed that women who were once in hospital for mental illness can be trusted as a babysitter (31% neither agree/disagree)

62% agreed that they would not want to live next door to someone who has been mentally ill

60% agreed that a woman would be foolish to marry a man who has suffered from mental illness, even if he seems fully recovered

Department of Health Survey (2003) : http://www.doh.gov.uk/public/england.htm (1897 adults, 16+)

Stigma & Psychosis

70% of respondents rated people with schizophrenia as dangerous to others

80% rated people with schizophrenia as unpredictable

60% rated people with schizophrenia as difficult to talk to

50% thought people with schizophrenia would never recover

Crisp, A.H., et al. (2002). British Journal of Psychiatry, 177, 4-7. (1737

adults 16+)

TIPS – Norway DUP can be dramatically reduced through educational campaigns

ED:ITED:IT Mental Health Promotion

‘Mental health & Psychosis’ workshops for individuals working with young people (300 + attended)

‘Lunchtime workshops’ for MH professional staff - training in ‘Early Identification’ of psychosis (200 + attended)

Educational DVD’s created by service users of the Early Intervention Services

‘REDIRECT’ educational project for GP’s in ‘Early Signs’ of psychosis – reducing DUP





Which Therapy for at-risk clients?

Evidence base for effectiveness of different treatments for HR clients remains sparse

Psychological therapy suggested as more acceptable, less stigmatising to HR clients (Bentall & Morrison 2002)

Possible risk of pharmacological side-effects and high non-adherence if antipsychotics used (eg McGlashan et al. 2006)

Co-morbid symptoms (anxiety/depression etc) addressed by psychological interventions

ED:IT Sept 2004

Interventions – Birmingham ED:IT

flexible treatment options including …

Intervention Type Uptake n=50

Case Management 100.0%Individual CBT (Morrison & French, 2004) 86.7%Group CBT 24.4%Family Support/Intervention 35.5%Neuroleptic Meds (supplied by outside agency)

6.7%

EDIE2 (MRC funded UK Intervention Trial 2006 - 2010)

MRC funded Trial of CBT for individuals at high risk of psychosis

Aim to recruit n=320 high-risk participants To reduce transition to psychosis and

reduce the distress felt by help-seeking individuals

Inclusion using PACE at-risk criteria

What sites are involved in EDIE 2?

Manchester (lead site) Glasgow Birmingham/ Worcester East Anglia Cambridge

Check EDIE2 website at University of Manchester

That’s the theory… but does it work in practice?

Are we able to ‘detect’ young people in the pre-psychotic phase in the community?

Do these young people actually want help from (mental health) services?

Is the ‘help’ that we are offering acceptable to young people?

That’s the theory… but how is it working in practice?

Are we able to ‘detect’ young people in the pre-psychotic phase in the community?

Do these young people actually want help from (mental health) services?

Is the ‘help’ that we are offering acceptable to young people?

YES

A very Brief History of treatments for Psychosis (to remind us where we’ve

been…)

1403 - St Mary of Bethleham hospital near London first accepts psychiatric patients

(from 1776 this was also a tourist attraction)

Dunking Pool

Head Restraint

Restraining Crib (single occupancy)

1890 - Dr Gottlieb Burkhardt attempts to alter behaviour in 6 severely agitated Swiss patients by extracting portions of their frontal lobes (2 died)

Lobotomy Kit (NHS outreach model)

1913 - Emil Kraepelin categorises mental illnesses into those which could be cured and those which could not (e.g.dementia praecox - psychosis)

1938 - Cerletti and Bini introduce electroshock convulsions

Portable ECT Machine

1952 - Deniker Leborit & Delay discover the antipsychotic properties of chlorpromazine marking the beginning of psychopharmacology

1955 - More than 55,000 men women and children in the US undergo lobotomy

1985 - Ian Falloon trains GP’s to identify ‘early signs’ of psychosis

1990’s - EPPIC / PACE establish Early Detection/Intervention Clinical & Research programmes in Melbourne

- Early Intervention approaches introduced in UK and Internationally

- TIPS Norweigian educational campaigns reduce DUP

2000’s – First Early Detection / Prevention Programmes in UK

EDIE(2), ED:IT, OASIS, REDIRECT, BRITE







That’s a big jump in 20 years…







so what’s next…?

ED:IT Birmingham

Telephone: 0121-301 1850

Fax: 0121-301 1851

email: [email protected]

Documents

Introduction to At-Risk Mental States Why are we doing this work?